First-Trimester Diagnosis of Agnathia-Otocephaly Complex: A Series of 4 Cases and Review of the Literature.

First-trimester ultrasound findings in 4 fetuses with agnathia-otocephaly complex are described. In addition, information from 3 cases reported in the literature was also reviewed, for a total of 7 cases analyzed. All 7 fetuses presented with agnathia and 6 with ventrocaudal displacement of the ears (melotia/synotia). Four fetuses had holoprosencephaly. In 6 cases, the parents opted for termination of pregnancy. The remaining case resulted in premature delivery at 26 weeks due to severe polyhydramnios and early neonatal death. This report highlights the important role of ultrasound in the identification of agnathia-otocephaly complex in the first trimester of pregnancy.

First-trimester uterine artery Doppler velocimetry in the prediction of birth weight in a low-risk population.

OBJECTIVE: To study the relationship between first-trimester uterine artery (UtA) Doppler velocimetry and birth weight in an unselected, low-risk obstetric population. METHODS: This is a prospective study of 415 low-risk pregnant women who underwent a first-trimester ultrasound evaluation between 11 and 13 weeks of gestation. Blood flow velocimetry waveforms from both UtAs were obtained and the pulsatility index (PI) measured and recorded. Clinical records were reviewed for pregnancy outcomes. Birth weight was expressed as z-scores, and the Spearman correlation coefficient (ρ) was used to calculate the relationship between the mean, delta, and lowest UtA PI values and birth weight. RESULTS: There was no correlation between the mean and delta UtA PI values and birth weight. However, a significant correlation between the lowest UtA PI value and birth weight (ρ = -0.121; p = 0.013) was noted. CONCLUSIONS: Our study found a clinically significant correlation between the lowest UtA PI value and birth weight in an unselected, low-risk pregnant population. Because fetal growth is a multifactorial process in which placentation is only one of the factors involved, the use of a single parameter such as Doppler velocimetry remote from the delivery to predict birth weight in a low-risk population seems to be less useful than in the high-risk population.

Treatments for iron-deficiency anaemia in pregnancy.

BACKGROUND: Iron deficiency, the most common cause of anaemia in pregnancy worldwide, can be mild, moderate or severe. Severe anaemia can have very serious consequences for mothers and babies, but there is controversy about whether treating mild or moderate anaemia provides more benefit than harm. OBJECTIVES: To assess the effects of different treatments for anaemia in pregnancy attributed to iron deficiency (defined as haemoglobin less than 11 g/dL or other equivalent parameters) on maternal and neonatal morbidity and mortality. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2011), CENTRAL (2011, Issue 5), PubMed (1966 to June 2011), the International Clinical Trials Registry Platform (ICTRP) (2 May 2011), Health Technology Assessment Program (HTA) (2 May 2011) and LATINREC (Colombia) (2 May 2011). SELECTION CRITERIA: Randomised controlled trials comparing treatments for anaemia in pregnancy attributed to iron deficiency. DATA COLLECTION AND ANALYSIS: We identified 23 trials, involving 3.198 women. We assessed their risk of bias. Three further studies identified are awaiting classification. MAIN RESULTS: Many of the trials were from low-income countries; they were generally small and frequently methodologically poor. They covered a very wide range of differing drugs, doses and routes of administration, making it difficult to pool data. Oral iron in pregnancy showed a reduction in the incidence of anaemia (risk ratio 0.38, 95% confidence interval 0.26 to 0.55, one trial, 125 women) and better haematological indices than placebo (two trials). It was not possible to assess the effects of treatment by severity of anaemia. A trend was found between dose and reported adverse effects. Most trials reported no clinically relevant outcomes nor adverse effects. Although the intramuscular and intravenous routes produced better haematological indices in women than the oral route, no clinical outcomes were assessed and there were insufficient data on adverse effects, for example, on venous thrombosis and severe allergic reactions. Daily low-dose iron supplements may be effective at treating anaemia in pregnancy with less gastrointestinal side effects compared with higher doses. AUTHORS' CONCLUSIONS: Despite the high incidence and burden of disease associated with this condition, there is a paucity of good quality trials assessing clinical maternal and neonatal effects of iron administration in women with anaemia. Daily oral iron treatment improves haematological indices but causes frequent gastrointestinal adverse effects. Parenteral (intramuscular and intravenous) iron enhances haematological response, compared with oral iron, but there are concerns about possible important adverse effects (for intravenous treatment venous thrombosis and allergic reactions and for intramuscular treatment important pain, discolouration and allergic reactions). Large, good quality trials, assessing clinical outcomes (including adverse effects) as well as the effects of treatment by severity of anaemia are required.

Doppler fetoplacentario en hipertensión gestacional y preeclampsia leve / The usefulness of fetal placental doppler ultrasound in gestational hypertension and mild preeclampsia

Introducción: la preeclampsia se presenta en 6% de los embarazos en Colombia y se asocia con una elevada tasa de morbimortalidad maternofetal. Con frecuencia los casos severos se acompañan de restricción del crecimiento intrauterino; en estos casos el doppler fetoplacentario es útil para determinar el pronóstico fetal, pero su valor en preeclampsia leve o hipertensión gestacional no está bien definido. Objetivos: determinar en estas dos circunstancias la frecuencia de alteraciones en el doppler de las arterias umbilical y cerebral media. Materiales y métodos: búsqueda de casos en la base datos de la unidad de medicina maternofetal del Hospital de San José, entre agosto de 2006 y febrero de 2008. Se definió como casos las pacientes con gestaciones > a 28 semanas con HTG o PL y fetos con perfil de crecimiento normal. Se consideraron y analizaron variables demográficas, resultados del doppler fetoplacentario y las complicaciones. Resultados: se identificaron 85 pacientes. El 17% presentó alteración del doppler de la AU y 7% de la ACM; en gestaciones < 32 semanas los hallazgos anormales son bajos (75% AU y 85% ACM normales). Conclusiones: la frecuencia de alteraciones en el Doppler de AU y ACM fue similar en el grupo de mujeres que presentaron complicaciones y aquellas con un desenlace normal.

Introduction: In Colombia, around 6% of pregnant women will experience preeclampsia. It is associated with high maternal and fetal morbidity and mortality rates. Severe cases are frequently related to intrauterine growth restriction; placental and fetal Doppler has prognostic value in these cases, although, its usefulness in mild preeclampsia (MP) or gestational hypertension (GHT) is not yet well defined. Objectives: to determine the frequency of abnormal Doppler sonography of the umbilical artery (UA) and middle cerebral artery (MCA) in MP or GHT. Materials and methods: cases were searched for in the Maternal Fetal Unit databases at Hospital de San José between August 2006 and February 2008. Cases were defined as patients with > 28 week pregnancies complicated by GHT or MP with fetuses with a normal growth profile. Demographic variables, placental fetal Doppler evaluation results and complications were considered and analyzed. Results: 85 patients were identified. Seventeen percent (17 %) presented abnormal Doppler of the UA and 7% of the MCA; abnormal findings were low (normal UA in 75% and normal MCA in 85%) in < 32 week gestations. Conclusions: the frequency of abnormal Doppler results of the UA and MCA were similar in the group of women with complications and in those who had a normal pregnancy outcome.

First-trimester nasal bone length in a normal Latin American population.

OBJECTIVES: To report normative data of nasal bone length (NBL) in first-trimester singleton fetuses in a normal cohort of Latin American women. METHODS: NBL was measured during routine first-trimester sonographic examination in 1040 singleton fetuses from an unselected population. RESULTS: NBL increased linearly with advancing gestational age (GA) [NBL (mm) = - 1.10 + 0.03 x GA (days), R(2) = 0.21; p < 0.001]. Similarly, there was a linear relationship between the NBL and crown-lump length (CRL) [NBL (mm) = 0.41 + 0.02 x CRL (mm), R(2) = 0.27; p < 0.001]. The NBLs at the 50th percentile in our population were 1.5, 1.7, and 1.9 mm at 11, 12, and 13 weeks of gestation, respectively. CONCLUSIONS: Whereas categorizing a nasal bone as absent or present can be subjective because of variations in echogenicity due to technique and equipment, measurement of NBL is a more objective approach to nasal bone assessment in screening for aneuploidy. Measurement of NBL in the first trimester is feasible and can be easily obtained at the time of nuchal translucency assessment. The normative data we report can provide a reference for defining nasal bone hypoplasia in the first trimester in the Latin American population.

Congenital diaphragmatic hernia in a first-trimester ultrasound aneuploidy screening program.

OBJECTIVES: To review our experience with the prenatal detection of congenital diaphragmatic hernia (CDH) in fetuses presenting for ultrasound screening of chromosomal abnormalities in the first trimester. METHODS: As part of our first-trimester ultrasound protocol, fetuses with a crown-rump length between 45 and 84 mm underwent a limited anatomical assessment in conjunction with nuchal translucency thickness measurement and nasal bone assessment. Cases of CDH diagnosed prenatally or after delivery in this population were identified. RESULTS: Among the six cases of CDH detected (prevalence of 1 in 927), the first-trimester ultrasound findings were abnormal in five fetuses (83%), including three with increased nuchal translucency only; one with increased nuchal translucency, an intrathoracic stomach, dextrocardia and a cephalocele; and one with normal nuchal translucency thickness and a small, complex intrathoracic mass later confirmed as the fetal stomach. The diagnosis of CDH was confidently made in the first trimester in one case, in the second trimester in three cases, and after birth in the remaining two cases. CONCLUSION: The diagnosis of CDH in the first trimester is difficult, especially in those cases in which the defect is small or late migration of the abdominal viscera occurs. Therefore, screening for CDH in the first trimester is unlikely to be effective.

Nuchal translucency thickness in monochorionic multiple pregnancies: value in predicting pregnancy outcome.

OBJECTIVES: The purpose of this study was to investigate the value of first-trimester nuchal translucency (NT) thickness in predicting the pregnancy outcome in monochorionic multiple pregnancies. METHODS: Thirty monochorionic multiple pregnancies were evaluated for NT thickness at a median gestational age of 12 weeks (range, 11-14 weeks). Information on pregnancy outcome was obtained from all cases. A poor pregnancy outcome was defined as fetal death or miscarriage before 24 weeks, development of twin-twin transfusion syndrome (TTTS), or preterm delivery before 32 weeks. RESULTS: The NT thickness was above the 95th percentile for gestational age in at least 1 fetus in 5 (17%) pregnancies, and a poor pregnancy outcome was recorded in 14 (47%) pregnancies. The overall sensitivity was 36% (5/14); specificity, 100% (16/16); positive predictive value, 100% (5/5); and negative predictive value, 64% (16/25). In pregnancies with increased compared with normal NT thickness, no significant correlation was found with the subsequent development of TTTS (1/5 [20%] versus 5/25 [20%]) and miscarriage or fetal death before 24 weeks (1/5 [20%] versus 3/25 [12%]). However, among the 20 pregnancies not complicated by TTTS or loss before 24 weeks, there was a significantly increased rate of delivery before 32 weeks in the former group (3/4 [75%] versus 1/16 [6.3%]; P = .01). CONCLUSIONS: In monochorionic multiple pregnancies, an increased NT thickness measurement had a high specificity and positive predictive value for adverse perinatal outcomes. However, the sensitivity and negative predictive value were low, with a normal NT thickness measurement poorly predicting development of complications; therefore, close sonographic follow-up should be carried out in all cases, irrespective of NT thickness.

Condiloma acuminado gigante: presentación de un caso / Giant Condyloma Acuminatum: A Case Report

El condiloma acuminado gigante (CAG) de la región anorrectal es una enfermedad rara, descrita originalmente en 1896 y que tiene un curso habitualmente fatal. Se caracteriza por la presencia de una lesión bien diferenciada de difícil tratamiento, debido a las dimensiones del tumor, por el extenso compromiso locorregional y la alta tasa de recurrencias. El CAG se ha diferenciado del condiloma común y del carcinoma escamocelular típico por el grosor de su estrato córneo, por la rápida proliferación papilar y por la ausencia de compromiso de la membrana basal, angioinvasión, infiltración linfática y metástasis. A continuación, se presenta el caso de una mujer con un CAG tratado con quimiorradiación.Palabras clave: condiloma acuminado, carcinoma verrucoso, queratoacantoma, carcinoma del canal anal.

Giant condyloma acuminatum (GCA) of the anorectum is a rare disease with potentially fatal course, originally described in 1896. Although this is a well differentiated tumor, its management is often challenging due to the size, degree of local invasion and recurrence rate. GCA can be differentiated from ordinary condiloma and squamous cell carcinoma because of its thicker stratum corneum, marked papillary proliferation, invasion of the normal tissue without compromise of the basement membrane, angioinvasion, lymphatic infiltration and metastases. We report a case of a woman with CGA treated by chemoradiotehrapy.

Systematic review of case reports concerning adults suffering from neutropenic enterocolitis.

INTRODUCTION: Neutropenic enterocolitis (NEC) is a well recognised clinical-pathological and life-threatening complication in patients suffering from several conditions, including solid and haematological malignancies or aplastic anaemia. OBJECTIVE: This review was aimed at evaluating overall NEC mortality rate, describing clinical diagnostic findings and therapeutical interventions reported in the literature and generating a hypothesis regarding factors influencing mortality and surgical intervention. MATERIALS AND METHODS: An advanced search was made in Medline, Embase, Lilacs and Google. Additional strategies included manual search of specific journals. Reports were considered if they described case definition, inclusion and exclusion criteria. RESULTS: 275 cases were selected; 109 were from individual data and 40 from grouped data. Comparing data between case reports and case series revealed no significant differences related to mortality, surgical intervention, sex or age. Higher mortality (chi2 = 7.51 p = 0.006) was found in women (50%) compared to men (28%). No significant difference was found between antibiotic combinations and mortality (chi(2) = 12.85 df 13 p = 0.45). Mortality (chi2 = 3.89 df 1, p = 0.049), surgical intervention (chi2 = 7.64 df 1, p = 0.006) and duration of diarrhoea (chi2 = 4.71 df 1, p = 0.043) were significantly different in 26.4% of individuals using antifungal agents; death occurred in 81% of patients! who did not receive such medication compared to 19% individuals reported as being treated with antifungal agents. CONCLUSION: The current evidence suggests that antifungal agents should be used early in patients suffering from NEC. However, this hypothesis must be evaluated in multi-centric, randomised controlled trials.

Systematic review of case reports concerning adults suffering from neutropenic enterocolitis

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Introduction. Neutropenic enterocolitis (NEC) is awell recognised clinical-pathological and life-threateningcomplication in patients suffering from severalconditions, including solid and haematologicalmalignancies or aplastic anaemia.Objective. This review was aimed at evaluatingoverall NEC mortality rate, describing clinical diagnosticfindings and therapeutical interventions reportedin the literature and generating a hypothesisregarding factors influencing mortality and surgicalintervention.Materials and methods. An advanced search wasmade in Medline, Embase, Lilacs and Google. Additionalstrategies included manual search of specificjournals. Reports were considered if they describedcase definition, inclusion and exclusion criteria.Results. 275 cases were selected; 109 were from individualdata and 40 from grouped data. Comparingdata between case reports and case series revealedno significant differences related to mortality, surgicalintervention, sex or age. Higher mortality (÷2 =7.51 p = 0.006) was found in women (50%) comparedto men (28%). No significant difference wasfound between antibiotic combinations and mortality(÷2 = 12.85 df 13 p = 0.45).Mortality (÷2 = 3.89 df 1, p = 0.049), surgical intervention(÷2 = 7.64 df 1, p = 0.006) and duration of diarrhoea(÷2 = 4.71 df 1, p = 0.043) were significantly differentin 26.4% of individuals using antifungal agents;death occurred in 81% of patients! who did not receivesuch medication compared to 19% individualsreported as being treated with antifungal agents.Conclusion. The current evidence suggests that antifungalagents should be used early in patients sufferingfrom NEC. However, this hypothesis must beevaluated in multi-centric, randomised controlledtrials

Histeroscopia de oficina: experiencia en el servicio de ginecología y obstetricia del Hospital de San José / Office hysteroscopy: experience in the service of obstetrics and gynecology at the San José Hospital

Introducción: la histeroscopia se considera un método diagnóstico y terapéutico que permite en forma simultánea la visualización de la cavidad endometrial y la obtención de biopsias, así como la realización de diferentes procedimientos quirúrgicos. Se ha practicado bajo anestesia general con dilatación del orificio cervical interno; sin embargo, en la última década los equipos modernos y en particular las especificaciones de forma y diámetros del instrumental, han permitido la ejecución del procedimiento sin requerir anestesia. Bajo estas condiciones la histeroscopia se denomina oficinal o de consultorio (HDC). Objetivos: describir el tiempo medio de realización de la HDC, los hallazgos en el procedimiento en relación con los descritos en la ecografía y la histerosonografía, la proporción de mujeres en las cuales se puede acceder a la cavidad endometrial para analizar la eficacia y la tolerancia al mismo sin anestesia en el Hospital de San José. Materiales y métodos: entre mayo de 2004 y noviembre de 2005 se estudiaron 30 pacientes a quienes se les realizó HDC con fines diagnósticos y terapéuticos, practicados por el mismo cirujano. Se describió la tolerancia de la paciente al procedimiento y su relación con posibles antecedentes quirúrgicos u obstétricos. También se anotaron los hallazgos quirúrgicos más frecuentes y la concordancia con los métodos diagnósticos realizados previos al procedimiento. Resultados: el estudio de las 30 pacientes reveló una edad media de 37 años. El diagnóstico ecográfico más frecuente fue de pólipos endocervicales en un 31% al igual que en la histerosonografía (27.6%). El tiempo medio fue de 5.14 minutos, el dolor reportado según la escala análoga fue 3.66 y la tolerancia del procedimiento 86%. Conclusiones: la histeroscopia es un método diagnóstico y terapéutico sencillo y bien tolerado para procedimientos quirúrgicos menores en la cavidad endometrial. La tolerancia en esta serie de casos es similar a la reportada en series mayores, aunque el porcentaje de ingreso a la cavidad endometrial es menor.

Enterocolitis neutropénica: revisión sistemática de casos publicados / Systematic review of case reports concerning adults suffering from neutropenic enterocolitis

Introducción: La enterocolitis neutropénica (ECN) es una entidad clínico patológica bien reconocida que amenaza habitualmente la vida y se asocia con diversas neoplasias sólidas y hematológicas y con la anemia aplásica.Objetivo: Evaluar la mortalidad global de la ECN, describir los hallazgos clínicos más frecuentes y las intervenciones terapéuticas reportadas en la literatura médica, con la finalidad de generar hipótesis acerca de los factores que influyen sobre la mortalidad y en la realización de intervenciones quirúrgicas.Materiales y métodos: Se realizaron búsquedas avanzadas en las bases de datos Medline, Embase, Lilacs y en el motor general Google; además, se utilizaron como estrategias adicionales, búsquedas manuales en diversas revistas. Los reportes fueron considerados según la definición del caso teniendo en cuenta criterios específicos para inclusión y exclusión.Resultados: Se seleccionaron 228 casos; 109 fueron casos individuales y 40 reportes correspondieron a series de casos. La comparación de los datos obtenidos a partir de los reportes individuales y de las series de casos no reveló diferencias significativas respecto de la mortalidad, intervenciones quirúrgicas, edad y sexo. Se encontró una mortalidad mayor en las mujeres (2=7,51 p=0,006) comparadas con los hombres (50porciento. No se identificaron diferencias significativas entre las combinaciones de antibióticos respecto de la mortalidad (2=12,85 df 13 p=0,45). La mortalidad (2=3,89 df 1, p=0,049), las intervenciones quirúrgicas (2=7,64 df 1, p=0,006) y la duración de la diarrea (2=4,71 df 1, p=0,043) fueron significativamente diferentes en el 26,4porcientondividuos que fueron tratados con antifúngicos; el 81porciento pcientes que no recibieron estos medicamentos murieron, en comparación con el 19porcientoujetos en que se reportó la utilización de antimicóticos.Conclusión: La evidencia sugiere que los agentes antifúngicos deben ser usados tempranamente en los pacientes que padecen ECN. Sin embargo, esta hipótesis debe ser evaluada en experimentos clínicos multicentricos con asignación aleatoria.

Leishmaniasis lupoide / Lupus-like Leishmaniasis

La primera descripción de leishmaniasis en América Latina fue hecha por Migone en 1913 y en Colombia en 1944 porAugusto Gast-Galvis. Hasta el momento, ha sido registrada en 88 países del mundo, donde ocurren anualmente alrededorde 12 millones de casos y existen aproximadamente 350 millones de personas en riesgo de contraer la enfermedad. En losúltimos cinco años, se han reportado alrededor de 6.500 casos nuevos en Colombia. Se realiza el recuento histórico del casode una mujer de 27 años con el diagnóstico de leishmaniasis vegetante centrofacial, tratada en 1935 con telecuriterapiaen el Instituto Nacional de Radium.

Reconstrucción vaginal con técnica modificada de McIndoe: experiencia de 18 años en el Hospital de San José, Bogotá D.C. Colombia / Vaginal reconstruction with a modified McIndoe technique: 18 years of experience in the Hospital de San José, Bogotá DC Colombia

Las malformaciones congénitas del aparato genital femenino representan un verdadero desafío para la ginecología y lacirugía plástica reconstructiva. Las anomalías de la fusión de los conductos de Müller pueden producir una diversidad dealteraciones del útero o la vagina. La incidencia de malformaciones mullerianas y específicamente de agenesia de la vaginase estima en un 0,1% - 1,5% de la población general, se ha asociado con otras malformaciones congénitas y con el síndromede Mayer-Rokitansky-Kluster-Hauser. La reconstrucción vaginal supone un gran reto con algunos objetivos fundamentalescomo ofrecer solución a la ausencia total o parcial vaginal en un solo tiempo quirúrgico, construir una neovagina con unángulo de inclinación fisiológico y natural y un eje anatómico correcto para la relación sexual, conseguir característicasdeseables como sensibilidad, distensibilidad y elasticidad, minimizar la morbilidad de las zonas donantes de los tejidosutilizados en la reconstrucción y evitar la necesidad de uso continuo de moldes, obturadores o dilatadores. Existen múltiplesprocedimientos reconstructivos, quirúrgicos y no quirúrgicos descritos. Este artículo presenta la experiencia del Hospitalde San José, Bogotá D.C. Colombia, con este tipo de patología, utilizando el método de McIndoe, modificado, durante unperíodo de 18 años.