Spontaneous Hemoperitoneum due to Rupture of Uterine Varicose Veins during Labor Successfully Treated by Percutaneous Embolization.

Hemoperitoneum during pregnancy is a rare but potentially lethal clinical condition. Improvements in antenatal and intrapartum care, especially in surgical and anesthetic techniques, have reduced maternal mortality; perinatal mortality remains very high (31%). Treatment is based on the systemic correction of hypovolemia and immediate surgery via laparotomy or laparoscopy in cases in the first trimester of pregnancy for hemostatic purposes. Sometimes, hysterectomy is needed. A 35-year-old Asiatic primigravid woman at 37 weeks' gestation with otherwise uneventful pregnancy came to the hospital referring abrupt-onset lumbar and abdominal pain. A bleeding uterine superficial varicocele of about 7 cm was found on the left uterine horn during Caesarean section. Interventional radiologic embolization of both uterine arteries was successfully performed. Posterior evolution of the patient was favorable. Percutaneous vascular embolization of the uterine arteries is an effective alternative treatment for many obstetrical and gynecological causes of bleeding. The main advantage of this technique is the low rate of serious complications and the preservation of reproductive function. To our knowledge, this is the first case of spontaneous intrapartum hemoperitoneum treated with this technique. An early diagnosis and a rapid indication of this therapeutic option are essential. Hemodynamic stability is needed to decide this conservative management.

[Twin pregnancy with intrauterine death of one fetus: maternal and neonatal outcome of surviving fetus]. / Gestación gemelar con muerte intraútero de uno de los fetos: pronóstico materno y neonatal del feto superviviente.

BACKGROUND: happens in the womb when the death of one of the twins, it is necessary to consider the factors that influence the perinatal outcome of surviving fetus. OBJECTIVE: To review the outcome of twin pregnancies complicated by single fetal intrauterine death and how it can increase morbidity to its co-twin and its mother. MATERIAL AND METHODS: A retrospective analysis of the fifty one twin pregnancies complicated by single fetal intrauterine death in the second or third trimester in our centre from December 1999 to December 2010. RESULTS: Of the total amount of 1996 twin pregnancies attended in our centre, 51 were complicated by single fetal intrauterine death (2.5%). In 68.7% of the cases we found several maternal complications, such as 12.2% of preeclampsia and 12% of coagulopathies. As for the dead foetus, there was a 47% of malformations, a 19.6% of intrauterine fetal growth restriction and there was a 9.8% of cases complicated by twin-twin transfusion syndrome. In the group of the surviving co-twin, 9.8% developed intrauterine growth restriction, 9.8% oligohydramnios and 9.8% Doppler alterations. There was a high risk of prematurity with 43.1% of the births under 34 weeks and 13.7% under 30 weeks of pregnancy. The percentage of caesarean was 64.7%. There was 3 cases of co-twin died intra-uterus, and one more died postpartum. A 10% of the newborns had some kind of neurological disability. CONCLUSIONS: It seems that surviving co-twin prognosis is mainly compromised by prematurity and its consequences. There should be more prospective research to inform decision-making and evaluate and control the potential maternal and fetal risks.

Hemorragia fetomaterna masiva como causa de hidrops en gestación a término: reporte de caso y revisión de la literatura / Massive fetomaternal hemorrage cause hydrops in pregnancy at term: case report and literature revision

Objetivo: la hemorragia fetomaterna masiva es una complicación rara del embarazo, que puede causar anemia fetal severa y muerte fetal intrauterina. Se presenta un caso clínico con el objetivo de hacer una revisión de la fisiopatología del diagnóstico y del tratamiento Materiales y métodos: se presenta el caso clínico de una mujer en la semana 39 de embarazo, remitida al Hospital La Paz de Madrid, centro de referencia de atención materna y perinatal, por signos ecográficos de hidrops y de insuficiencia cardíaca derecha. El registro cardiotocográfico evidenció un patrón sinusoidal. La recién nacida presentó acidosis metabólica y anemia severa. El estudio anatomopatológico de la placenta fue sugestivo de anemia fetal crónica. El test de Kleihauer-Betke evidenció hemorragia fetomaterna de 90-100 ml. Se realizó una búsqueda bibliográfica en las bases de datos Medline vía Pubmed, EMBASE, LILACS y SciELO y la biblioteca Cochrane. Conclusión: el diagnóstico intrauterino es difícil, se debe sospechar cuando una mujer refiere reducción de movimientos fetales y cuando el registro cardiotocográfico muestra un patrón sinusoidal. En general, el estudio ecográfico es anodino, el Doppler de la arteria cerebral media puede ayudar en la identificación de los casos de anemia fetal, donde se evidencia un aumento del pico sistólico. Es importante la identificación precoz de los casos afectados para empezar un tratamiento sintomático de la anemia...

Objective: massive fetomaternal hemorrhage is a rarely occurring complication during pregnancy which can cause severe fetal anemia and intrauterine fetal death. A clinical case is presented here to review the pertinent pathophysiology, diagnosis and treatment. Materials and methods: the case of a 39 weeks pregnant woman admitted to La Paz Hospital in Madrid is reported; this hospital is the center for perinatal and maternal attention. The patient was referred due to sonographic signs of hydrops and right heart failure. Cardiotocographic records showed a sinusoidal pattern. The newborn presented metabolic acidosis and severe anemia. Pathologic examination of the placenta was suggestive of chronic fetal anemia. The Kleihauer-Betke test revealed a 90-100 ml fetomaternal hemorrhage. A literature search was made in Medline via Pubmed, EMBASE, LILACS and SciELO and the Cochrane Library. Conclusion: intrauterine diagnosis is difficult; massive fetomaternal hemorrhage should be suspected when a woman refers to reduced fetal movements and when the record shows a sinusoidal pattern in cardiotocography. Ultrasound is usually bland and Doppler of the middle cerebral artery may help in identifying cases of fetal anemia, revealing an increased systolic peak. Such cases must be identified early on to start symptomatic treatment of anemia...

Rotura espontánea de la vena renal izquierda materna durante la gestación / Spontaneous rupture of the maternal left renal vein during pregnancy

La hemorragia retroperitoneal es un evento raro, y aún más durante la gestación, asociándose a una alta morbimortalidad, tanto materna como perinatal. Su origen suele ser traumático, aunque se puede producir de manera espontánea, lo que dificulta todavía más su diagnóstico. Entre sus síntomas de presentación se deben destacar el dolor abdominal y el shock hipovolémico maternos, junto con un rápido compromiso fetal. En este contexto, se presenta el caso de una hemorragia retroperitoneal materna, acontecida en la semana 35 y debida a la rotura espontánea de la vena renal izquierda, aunque comenzó con un cuadro de abruptio placentae (AU)

Retroperitoneal hemorrhage is a very rare event, especially during pregnancy, and is associated with high morbimortality for both the mother and fetus. The cause is usually traumatic, but these hemorrhages can occur spontaneously, which further hampers their diagnosis. Presenting symptoms are abdominal pain and maternal hypovolemic shock, with rapid fetal compromise. We present a case of maternal retroperitoneal hemorrhage, which occurred at week 35 of pregnancy due to spontaneous rupture of the left renal vein, although the first manifestation was placental abruption (AU)

Corioamnionitis histológica y morbimortalidad neonatal: aproximación al síndrome de respuesta inflamatoria fetal / Chorioamnionitis neonatal morbidity: approach to fetal inflammatory response syndrome

Antecedentes: El síndrome de respuesta inflamatoria fetal (SRIF) es una entidad relacionada con la presencia de inflamación intrauterina y suele asociarse a infección intraamniótica. Su consecuencia más grave es la lesión cerebral y posterior desarrollo de parálisis cerebral. Objetivo: Evaluar la relación entre el síndrome de respuesta inflamatoria fetal y el desarrollo de complicaciones neonatales. Método: Estudio descriptivo y retrospectivo, realizado en el Hospital Universitario La Paz de Madrid, buscando una aproximación al SRIF desde la corioamnionitis histológica/funiculitis. El grupo de estudio constituido por 35 gestaciones simples pretérmino recogidas durante el primer semestre de 2008 y en las que la anatomía patológica de la placenta y anexos ovulares demostró la presencia de una corioamnionitis histológica y/o funiculitis. Resultados: Siete casos (20 por ciento) presentaban clínica sospechosa de infección intraamniótica, si bien en 28 gestantes (80 por ciento) existían factores de riesgo asociados al síndrome de respuesta inflamatoria fetal. Mortalidad perinatal en el grupo estudiado fue de 11,4 por ciento (4 casos). Sólo en 2 pacientes (5,7 por ciento) se pudo relacionar la muerte con el SRIF. En 28 recién nacidos (80 por ciento) se encontró algún tipo de patología, siendo la misma inherente a dicho síndrome en 17 casos (48,6 por ciento), destacando sepsis neonatal (40 por ciento), leucomalacia periventricular (14,3 por ciento) y displasia broncopulmonar (5,7 por ciento). Conclusión: Se comprueba el alto riesgo neonatal del SRIF. El conocimiento de esta condición, abre una serie de controversias diagnósticas y terapéuticas que obliga a una reevaluación de los protocolos actuales de manejo de la amenaza de parto pretérmino y la rotura prematura de membranas de pretérmino.

Background: The fetal inflammatory response syndrome (FIRS) is an entity related to intrauterine inflammation which is commonly associated with intraamniotic infection. The most serious consequence is the neurologic damage and the subsequent development of cerebral palsy. Aims: To evaluate the relationship between the fetal inflammatory response syndrome and the development of neonatal complications. Method: Descriptive and retrospective study realized in "La Paz" University Hospital of Madrid, looking for an approximation to the FIRS from histologic chorioamnionitis/funisitis. Group of study constituted by 35 single preterm gestations collected during the first semester of 2008 and in which the pathologic anatomy study of the placenta and annexes showed the presence of histological corioamnionitis and / or funisitis. Results: Suspicious clinic was found in 7 cases (20 percent) but in 28 cases (80 percent) risk factors associated to FIRS were present. Perinatal mortality found was 11.4 percent (4 cases). Only in 2 cases (5.7 percent) the cause was relationated with FIRS. Pathology associated was found in 28 newborn (80 percent), being 17 cases (48.6 percent) pathology associated with the fetal inflammatory response syndrome, enhancing neonatal sepsis (40 percent), periventricular leukomalacia (14.3 percent), and bronchopulmonar dysplasia (5.7 percent). Conclusion: It is verified that FIRS enteals a high neonatal risk. The knowledge of this entity opens some diagnostic and therapeutic controversies. Current management protocols of preterm labor and preterm premature rupture of membranes should be revised.

Cesárea corporal y miomectomía: indicaciones actuales / Classic cesarean section and myomectomy

Actualmente, tanto la realización de una cesárea corporal como la práctica de una miomectomía en el transcurso de una cesárea, suponen dos hechos muy infrecuentes. No obstante, en determinados casos, ambos procedimientos pueden ser necesarios. La cesárea corporal es una técnica quirúrgica poco menos que abandonada, si bien aún mantiene algunas indicaciones; y la exéresis de un mioma durante una cesárea está clásicamente contraindicada, salvo en circunstancias muy concretas. Sin embargo, hay que destacar que en los últimos años se está constatando un incremento significativo de ambos procedimientos, siendo las razones muy diversas (aumento de las gestaciones pretérmino que se finalizan por vía abdominal, incremento de la edad materna, mayores tasas de cesáreas, etc.). Se presenta el caso clínico de una gestante con un gran mioma localizado en segmento inferior uterino y en la que fue preciso llevar a cabo una cesárea corporal, seguida de una miomectomía.

Nowadays, it is very rare to perform both classic cesarean section or myomectomy during cesarean section. However, sometimes it is necessary to do them. The classic cesarean section is a very uncommon chirurgical technique, however, it still has some indications. The performance of a myomectomy during a cesárea section although it is to be avoided, it might be necessary under specific circumstances. However, it is necessary to emphasize that in recent years it is more and more frecuent to performe these chirurgical techniques, due to different reasons such as the increasing of preterm pregnancies that are finished by an abdominal delivery, the increasing of the age of pregnancy and higher cesarean rates. We present a case report of large myoma situated at the lower uterine segment. Classic caesarean section followed by myomectomy was performed to allow the delivery.