Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor?

OBJECTIVE: To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. METHODS: This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. RESULTS: In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). CONCLUSION: When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Differences in characteristics of mediolateral episiotomy in proffesionals at the same hospital.

OBJECTIVES: The objective of our study was to compare the theoretical concept of the accoucheur in our institution with regard to the characteristics of the mediolateral episiotomy (MLE), with a crowning head and after a delivery. METHODS: We devised two simple pictorial questionnaires (one with a crowning head and the other in rest after a delivery) in order to explore possible differences in clinical practice between the accoucheurs of our institution with respect to the MLE characteristics. RESULTS: With a crowning head, we found more acute angles when the age of accoucheurs was greater than 35 years old and more than 15 years of experience, but no with the perineum at rest. No difference was found between doctors and midwives, nor between males and females. 28.1% of accoucheurs indicated an acuter episiotomy angle with a crowning head. CONCLUSION: This study confirmed that the individual interpretation of MLE differed widely among professionals at the same hospital. These differences which have been shown could predispose women to a greater risk of anal sphincter injuries. For this reason, there is a need to standardize this practice, to make the technique more homogeneous, particularly in the context of future research into the risks and benefits of episiotomy with respect to major perineal trauma.

p73 is required for endothelial cell differentiation, migration and the formation of vascular networks regulating VEGF and TGFß signaling.

Vasculogenesis, the establishment of the vascular plexus and angiogenesis, branching of new vessels from the preexisting vasculature, involves coordinated endothelial differentiation, proliferation and migration. Disturbances in these coordinated processes may accompany diseases such as cancer. We hypothesized that the p53 family member p73, which regulates cell differentiation in several contexts, may be important in vascular development. We demonstrate that p73 deficiency perturbed vascular development in the mouse retina, decreasing vascular branching, density and stability. Furthermore, p73 deficiency could affect non endothelial cells (ECs) resulting in reduced in vivo proangiogenic milieu. Moreover, p73 functional inhibition, as well as p73 deficiency, hindered vessel sprouting, tubulogenesis and the assembly of vascular structures in mouse embryonic stem cell and induced pluripotent stem cell cultures. Therefore, p73 is necessary for EC biology and vasculogenesis and, in particular, that DNp73 regulates EC migration and tube formation capacity by regulation of expression of pro-angiogenic factors such as transforming growth factor-ß and vascular endothelial growth factors. DNp73 expression is upregulated in the tumor environment, resulting in enhanced angiogenic potential of B16-F10 melanoma cells. Our results demonstrate, by the first time, that differential p73-isoform regulation is necessary for physiological vasculogenesis and angiogenesis and DNp73 overexpression becomes a positive advantage for tumor progression due to its pro-angiogenic capacity.

Trigonometric characteristics of episiotomy and risks for obstetric anal sphincter injuries in operative vaginal delivery.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to investigate the association between the trigonometric properties of episiotomy in operative vaginal delivery (OVD) and obstetric anal sphincter injuries (OASIS). METHODS: The study included 72 primiparous women who had an OVD and episiotomy. Cases (n = 36) had sustained OASIS at birth, while controls (n = 36) had not. The groups were matched for instrumental delivery. The episiotomy scar was identified and its trigonometric characteristics were measured at 8-12 weeks postpartum. Data were analysed using conditional logistic analysis. RESULTS: The angle of episiotomy behaves as a factor associated with anal sphincter injury, so women with a mediolateral episiotomy and an angle greater than 20° have an 87% less risk of having an OASIS (odds ratio 0.13, 95% confidence interval 0.03-0.58). The study showed that scarred episiotomies at 8-12 weeks after OVD with an angle ≤ 20°, depth and distance between the episiotomy and anus ≤ 15 mm, total upper triangle perimeter ≤ 75 mm, para-anal triangle perimeter ≤ 15 mm and areas between scar and midline ≤ 250 mm(2) were significantly associated with higher risk of OASIS. CONCLUSIONS: When a mediolateral episiotomy is performed in OVD the technique has a strong effect on the occurrence of OASIS. Additional research is needed to determine if the optimal technique for mediolateral episiotomies produces less OASIS than deferring the performance of episiotomy.

Índice de masa corporal y aumento de peso en el embarazo. Resultado obstétrico de la inducción de parto / Body mass index and gestational weight gain. Pregnancy outcomes after labor induction

Objetivo: Determinar el resultado de la inducción de parto en función del índice de masa corporal (IMC) materno y del aumento de peso en el embarazo en el Hospital de León en el periodo enero-marzo de 2008.Material y método Estudio de cohortes prospectivo. Analizamos 127inducciones de parto. Incluimos las variables: causa de la inducción, procedimientos de maduración cervical e inducción empleados, edad materna al fin de la gestación, tipo de parto, paridad, test de Bishop inicial, IMC, peso, talla, incremento ponderal durante la gestación, peso del recién nacido y test de Apgar al primer y quinto minuto. Resultados Se realizó inducción en el 21,3% de los partos del periodo. En el 81,1% se consiguió parto vaginal. El 36,2% de las pacientes tenía sobrepeso, el 21,2% obesidad y el 4,7% obesidad mórbida. Conclusiones Se encontraron relaciones no significativas entre el fracaso de la inducción con el IMC (p=0,08) y con el aumento de peso (p=0,07), incrementando el porcentaje de partos por cesárea (AU)

Objective: To determine the obstetric results of labor induction in relation to body mass index(BMI) and gestational weight gain at the Leon Hospital between January and March, 2008.Material and method: We conducted a prospective cohort study of 127 labor inductions. The variables included were the medical reason for induction, the procedures employed for cervical ripening and induction, maternal age at the end of pregnancy, type of labor, parity, initial Bishop’s score, BMI, weight, height, gestational weight gain, neonatal weight and Apgar test at1 and 5 minutes. Results Inductions were performed in 21.3% of births, while vaginal delivery was achievedin 81.1%. A total of 36.2% of the patients were overweight, 21.2% were obese and 4.7% were morbidly obese. Conclusions: A non-statistically significant association was observed between failure of vaginal delivery and BMI (P = .08) and body weight gain (P = .07). These two variables seem to increase the chances of failure of cervical ripening and induction of labor, increasing the percentage of cesarean sections (AU)

Tuberculosis anexial simuladora de malignidad ovárica coexistente con neutropenia con metamizol / Ovarian tuberculosis mimicking carcinoma and neutropenia due to metamizol

Se presenta el caso de una paciente intervenida ante la sospecha ecográfica de carcinoma ovárico y marcadores tumorales elevados. La anatomía patológica diagnosticó tuberculosis anexial. Antes de la intervención debutó con fiebre y se siguió tratamiento empírico con metamizol. La paciente desarrolló granulopenia, que mejoró tras la retirada del fármaco (AU)

We describe the case of a patient who underwent surgery due to sonographic suspicion of ovarian carcinoma and high tumoral marker levels. The histopathological analysis revealed adnexal tuberculosis. Before the surgery, the patient presented with fever and empirical metamizole treatment was administered. The patient developed granulopenia, which improved after withdrawal of the drug (AU)

Tumor de Krukenberg primario ovárico: un hallazgo infrecuente / Primary ovarian Krukenberg tumor: an infrequent finding

El tumor de Krukenberg es un adenocarcinoma ovárico raro que tiene una anatomopatología peculiar. Aunque habitualmente representa una metástasis de origen digestivo, en este estudio se presenta un caso con análisis morfológico e inmunohistoquímico de Krukenberg sin que demostrara la existencia de tumor primario extraovárico (AU)

Krukenberg tumor is a rare ovarian adenocarcinoma with characteristic histopathological features. Although this tumor usually represents metastasis from a digestive carcinoma, we present a case morphologically and immunohistochemically identified as ovarian Krukenberg tumor, no extraovarian primary tumor was detected (AU)

Carcinoma escamoso primario de mama posradiación / Postradiation primary squamous cell carcinoma of the breast

El carcinoma escamoso (CE) primario de mama es una entidad rara dentro de las neoplasias malignas de mama. Su clínica, diagnóstico y tratamiento no difieren del resto de los tumores de mama. El pronóstico es controvertido y la supervivencia a los 5 años es del 50 al 60%. A continuación se presenta el caso de una mujer que sufrió CE primario de mama 11 años después del tratamiento con radioterapia por un carcinoma ductal infiltrante de mama (AU)

Primary squamous cell carcinoma of the breast is a rare entity within malignant neoplasm of the breast. The clinical features, diagnosis and treatment do not differ from those of other breast tumors. Prognosis is controversial and 5-year survival is 50–60%. We report a case of primary squamous cell carcinoma of the breast 11 years after treatment with radiotherapy for an infiltrating ductal breast carcinoma (AU)

Drenaje y aspiración asistidos por imagen: alternativas conservadoras frente a cirugía en los abscesos pélvicos / No disponible

Una posible complicación después de cualquier cirugía es la infección, y el absceso es una forma de infección localizada en el lugar donde se ha trabajado. En el caso que se presenta la paciente fue diagnosticada de abscesos bilaterales en las regiones de las linfadenectomías de los vasos ilíacos. La administración de antibióticos intravenosos de amplio espectro no halló respuesta y se optó por la aspiración guiada por imagen, que consiguió una rápida mejoría de la paciente, evitando someterla a cirugía. Los grandes avances en las técnicas de imagen han facilitado el progreso en radiología intervencionista, y trabajando conjuntamente ginecólogos y radiólogos se podrá optar a tratamientos eficaces y poco invasivos que hasta hace unos años eran impensables (AU)

A possible complication after surgery is infection. An abscess is an infection localized in the surgical site. We present the case of a patient who was diagnosed with bilateral abscesses in the lymphadenectomy area, around the iliac vessels. Administration of wide spectrum intravenous antibiotics produced no response and image-guided aspiration was performed. This technique proved successful in the treatment of our patient, avoiding the need for open surgery. The major advances achieved in imaging techniques have aided progress in interventional radiology. The combination of gynecology and radiology could provide effective and relatively non-invasive treatments, which were unthinkable until a few years ago (AU)

Asistencia a la gestante con VIH-sida en el período 1996-2006 en el Hospital de León / HIV-AIDS pregnancy management from 1996 to 2006 at the Hospital de León (Spain)

Objetivo. Valoración del tratamiento y seguimiento de la gestante con VIH-sida en el Hospital de León en el período 1996-2006. Material y método. Estudio observacional, descriptivo y retrospectivo. Se analizaron 21.780 nacimientos, 18 gestantes con VIH-sida con 21 partos. Especial hincapié en las variables relativas al momento del parto. Resultados. Prevalencia del VIH-sida del 1‰, tratamiento TARGA el 47%, embarazos a término el 95%, cesáreas el 71,5%. Una única malformación congénita menor. Transmisión vertical en gestantes diagnosticadas antes del parto del 4,7%. Conclusiones. La asistencia fue adecuada y acorde con los protocolos de la SEGO. No se observó alta incidencia de efectos adversos ni patología obstétrica (AU)

Objective. To evaluate the treatment and follow-up of pregnant women with HIV-AIDS at the Hospital de León from 1996 to 2006. Material and method. We performed an observational, descriptive, retrospective study. A total of 21,780 births and 18 pregnant women with HIV-AIDS with 21 labors were analyzed. Special emphasis was placed on labor-related variables. Results. The prevalence of HIV infection was 1%. Highly active antiretroviral therapy was used by 47%. Full term pregnancies were achieved in 95%. Cesarean sections were performed in 71.5%. There was one minor congenital malformation. Vertical transmission in pregnant women diagnosed before delivery occurred in 4.7%. Conclusions. The treatment and follow-up provided to pregnant women with HIV-AIDS was adequate and in accordance with the protocols of the Spanish Society of Obstetrics and Gynecology. The incidence of adverse effects and obstetric pathology was not high (AU)

Miastenia gravis y gestación: caso clínico / Miastenia gravis and pregnancy: case report

La miastenia gravis es una enfermedad neuromuscular crónica, autoinmune, caracterizada por fatiga y debilidad fluctuante de la musculatura voluntaria de músculos oculares, faciales y de las extremidades. Hay un pico de incidencia en mujeres en la tercera década de la vida. El diagnóstico se realiza con el examen clínico, el test de tensilon, los estudios neurofisiológicos y la demostración de anticuerpos antirreceptor. El tratamiento incluye fármacos anticolinesterásicos, corticoides, inmunosupresores, plasmaféresis y timectomía. El efecto del embarazo en el curso de la enfermedad es variable, con un mayor riesgo de complicaciones durante el parto. Se expone la clínica, el diagnóstico y la conducta en una paciente atendida en nuestro hospital, dado el reducido número de casos comunicados en la bibliografía (AU)

Myasthenia gravis is a chronic autoimmune neuromuscular disorder characterized by fluctuating muscle weakness and fatigue of ocular, facial, bulbar and voluntary muscles. It has a bimodal peak of incidence with first peak in the third decade in women. The diagnosis is possible with the current test, electromyography and the presence of antibodies to acetylcholine receptors. Treatment may include anticholinesterase drugs, corticosteroids, plasmapheresis, immunosuppressive drugs and thymectomy. The clinical course of myasthenia gravis during pregnancy is variable, with an increased risk for complications during delivery. We analyse the clinical presentation, diagnosis, treatment and evolution of a patient in our hospital because of the slight number of cases we can find in the scientific literatura (AU)

Neoplasias mesenquimatosas vulvares: descripción de un caso de angiofibroma celular vulvar / Mesenchymal vulvar neoplasms: a case of cellular angiofibroma of the vulva

Se presenta el caso de una mujer de 61 años con una tumoración vulvar. Los análisis morfológico e inmunohistoquímico la identificaron como angiofibroma celular vulvar. Esta patología posee escaso poder de recurrencia local y no se han descrito metástasis. Las neoplasias mesenquimatosas vulvares requieren una extirpación con bordes libres y un correcto diagnóstico diferencial (AU)

We present the case of a 61-year-old woman who presented with a vulvar mass. Morphological and immunohistochemical analysis identified cellular angiofibroma. In this type of tumor, local recurrence is rare and metastasis has not bee described. Mesenchymal neoplasms of the vulva require surgical excision with free margins and accurate differential diagnosis (AU)

Tirotoxicosis en una gestación inducida por yodoprofilaxis / Thyrotoxicosis in pregnancy induced by iodine-prophylaxis

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Endometriosis extragenital / Extragenital endometriosis

Se define la endometriosis como un proceso invasivo, no neoplásico, caracterizado por endometrio activo fuera de la cavidad endometrial. Dentro del abdomen la localización más frecuente es la ovárica y la de la serosa peritoneal. Con menor frecuencia afecta al cérvix, vagina, vulva y pared abdominal. Excepcionalmente, se han descrito lesiones en tracto gastrointestinal, aparato urinario, nódulos linfáticos, pulmones, páncreas, hígado, cerebro y piel. En nuestro servicio, entre los años 1997 y 2004 se diagnosticaron 21 casos de endometriosis extragenital: endometriosis subcutánea o sobre cicatriz previa (8 casos), apendicular (4 casos), intestinal y en ganglios linfáticos (4 casos), aparato urinario (3 casos) y umbilical (2 casos) (AU)

Endometriosis is an invasive, non-neoplastic disease characterized by the presence of active endometrium outside the endometrial cavity. The most frequent abdominal localization is the ovary and the peritoneal serosa. Localization in the cervix, vagina, vulva and abdominal wall is less frequent. Endometriosis lesions in the gastrointestinal tract, bladder, lymphatic nodules, lungs, pancreas, liver, brain, and skin have been described very rarely. In our service, between 1997 and 2004 we diagnosed 21 cases of extragenital endometriosis: abdominal wall (8 cases), appendix (4 cases), gut and lymph nodes (4 cases), urinary tract (3 cases), and umbilicus (2 cases) (AU)

Tumores metastásicos de ovario: revisión de casos clínicos / Metastatic ovarian tumours: a review of clinical cases

Los tumores metastásicos suponen aproximadamente el 15% de los tumores malignos de ovario. Los tumores primarios más frecuentes derivan del tubo digestivo, la mama y el endometrio. Revisamos los tumores de ovario metastásicos diagnosticados en nuestro servicio de ginecología en los últimos 5 años. La edad media del diagnóstico fue de 56,96 años. Dos terceras partes fueron de origen no ginecológico, y el resto derivaron del aparato genital y la mama. La mitad de las pacientes presentaron un tumor primario gastrointestinal. La mayoría de las metástasis se diagnosticaron en segundo lugar, con un tamaño no superior a 5 cm y afectaron a un solo ovario. El componente predominante de las tumoraciones fue sólido. La clínica de las pacientes fue desde nula a dolor y crecimiento del perímetro abdominal. El tratamiento en todos los casos fue quirúrgico más quimioterapia y/o radioterapia. En la actualidad una tercera parte de las mujeres ha fallecido (AU)

Metastatic tumours constitute approximately 15% of malignant tumours of the ovary. The most frequent primary tumours derive from the gastrointestinal tract, breast and endometrium. We review the metastatic ovarian tumour diagnosed in our Service in the last five years. The average age at diagnosis was 56.96 years. Two thirds were of non-gynaecological origin and the rest derived from the gynaecological organs and the breasts. Half of the patients presented with a gastrointestinal primary. The majority of the metastasis were diagnosed afterwards, were 5 cm or less in size and affected only one ovary. The predominant component of the tumours was solid. The clinical history of these patients was from nothing to pain and an increase in abdominal size. Treatment in all cases was surgical with additional chemotherapy and/or radiotherapy. At present, one third of the women have died (AU)

Hígado graso agudo del embarazo: un diagnóstico inusual en obstetricia / Acute fatty liver of pregnancy: an unusual diagnosis in obstetrics

El hígado graso agudo del embarazo es una entidad infrecuente que afecta a la gestante durante el último trimestre del embarazo. Se caracteriza por un período prodrómico con síntomas como malestar general, náuseas, dolor epigástrico e ictericia. Analíticamente cursa con hiperbilirrubinemia, hipertransaminasemia, hipoalbuminemia, hipocolesterolemia, hipoglucemia y alteraciones de la coagulación. El tratamiento definitivo consiste en la terminación del embarazo. La biopsia hepática confirma el diagnóstico en casos atípicos. La mortalidad maternofetal se sitúa en torno al 20%. Se expone la presentación clínica, los parámetros analíticos, el tratamiento y la evolución de un caso clínico ocurrido en nuestro hospital, como contribución al escaso número de publicaciones (AU)

Acute fatty liver of pregnancy is an uncommon entity, which affects women during the last trimester of pregnancy. It is characterized by a prodromic period of symptoms such as uneasiness, nausea, epigastric pain, and jaundice. Analysis shows high levels of bilirubin, transaminase, hypoglycaemia and prolonged clotting time. Treatment is by ending the pregnancy immediately. Hepatic biopsy is useful for atypical cases. The maternal and fetal mortality rate is 20%. We analyze the clinical presentation, analytical parameters, treatment and evolution of this disease with the report of a clinical case in our hospital, as a contribution to the scarcity of available publications (AU)

Carcinoma de trompa de Falopio: revisión de 10 casos clínicos / Carcinoma of the fallopian tube: a review of 10 clinical cases

El carcinoma de trompa uterino es el menos frecuente de los carcinomas ginecológicos, y representa entre el 0,8 y el 1,5 por ciento de todos ellos. Su diagnóstico no suele ser preoperatorio, sino como hallazgo casual en piezas quirúrgicas. La edad media de las pacientes oscila en torno a los 60 años. Revisamos los casos de carcinoma de trompa de Falopio diagnosticados en nuestro servicio de ginecología entre los años 1993 y 2002. La edad media de las pacientes fue de 65,5 años. Los síntomas más frecuentes fueron hemorragia genital, seguido de masa abdominal y de dolor pelviano. Ningún caso fue diagnosticado preoperatoriamente. El 60 por ciento se encontraba en estadio I, el 20 por ciento en estadio II y el 20 por ciento en estadio III. Al 30 por ciento de las pacientes se le practicó cirugía y el 60 por ciento recibió tratamiento adyuvante de quimioterapia con cisplatino. Recogemos la sintomatología clínica, el diagnóstico, el tratamiento realizado y la evolución de las pacientes (AU)

Endometriosis umbilical / Umbilical endometriosis

La endometriosis umbilical es una enfermedad rara, pero debe considerarse entre los diagnósticos diferenciales en las lesiones umbilicales. Se presenta el caso de una mujer de 35 años de edad, con dolor periódico en el ombligo debido a una endometriosis umbilical. La paciente es nuligesta y no presenta antecedentes de cirugía pélvica (AU)

Struma ovarii: un tumor ovárico infrecuente / Struma ovarii: an unusual ovarian tumour

El struma ovarii como un teratoma monodérmico altamente especializado, en el cual el componente mayoritario es de tejido tiroideo. La baja frecuencia de presentación es una de sus principales características. Se expone el diagnóstico y conducta terapéutica en 4 pacientes en las que este tipo de tumor ovárico fue informado en nuestro hospital, dado el reducido número de series de struma ovarii comunicados en la bibliografía (AU)