Doença inflamatória pélvica: atualização / Inflammatory pelvic disease: updating

A doença inflamatória pélvica (DIP) consiste em espectro de infecções do trato genital superior que inclui: endometrite, salpingite, abscesso tubo-ovariano e/ou peritonite pélvica. Constitui-se em infecção polimicrobiana do trato genital superior feminino devido à sua contaminação pelos microrganismos do endocérvice e da vagina. São fatores de risco para o desenvolvimento de DIP: idade entre 15-24 anos, vida sexual ativa, múltiplos parceiros, inserção de dispositivo intra-uterino (DIU) há menos de 20 dias e história pregressa de DIP. Procedimentos e cirurgias pélvicos com manipulação de canal cervical podem predispor à infecção por alterarem a barreira cervical protetora. A DIP é um dos processos infecciosos mais frequentes nas mulheres em idade reprodutiva e é entidade de difícil diagnóstico devido às manifestações clínicas diversas. O diagnóstico é muito provável diante de dor à palpação cervical, uterina e/ou de anexos, acompanhados de febre, corrimento vaginal mucopurulento ou leucorreia, sangramento intermenstrual e pós-coito, dispareunia, disúria e polaciúria. O tratamento da DIP deve prover antibioticoterapia empírica de amplo espectro para os patógenos mais prováveis: N. gonorrhoeae e C. trachomatis, pois o rastreamento negativo para esses organismos não exclui infecção do trato reprodutivo superior. A precocidade das medidas terapêuticas é importante na prevenção de sequelas de longo prazo e a opção por tratamento ambulatorial ou hospitalar deve ser baseada no julgamento médico. Parceiros sexuais de mulheres com DIP devem ser examinados e tratados caso tenham tido relação sexual com a paciente nos 60 dias anteriores ao aparecimento dos sintomas. O rastreamento e tratamento da infecção por clamídia em mulheres sexualmente ativas diminui o risco de elas contraírem DIP. Grávidas com suspeita de DIP devem ser internadas para receber tratamento parenteral. Não foram estabelecidas diferenças nas manifestações clínicas da DIP em mulheres soropositivas e negativas para o HIV. Ambos os grupos respondem igualmente bem aos tratamentos parenteral e oral. (AU)

Pelvic Inflammatory Disease (PID) consists in a spectrum of upper genital tract infections including: endometritis, salpingitis, tube-ovarian abscess and / or pelvic peritonitis. It constitutes polymicrobial infection of upper female genital tract because of its contamination by microrganisms from the vagina and endocervix. Risk factors for the development of PID are: aged 15-24 years, sexual activity, multiple partners, insertion of an intrauterine device (IUD) for less than 20 days and a history of PID. Procedures and pelvic surgery with manipulation of the cervical canal may predispose to infection by altering the cervical protective barrier. PID is one of the most common infectious processes in women in reproductive age and it is an entity of difficult diagnosis due to the diverse clinical manifestations. The diagnosis is most likely on painful palpation of the cervix, uterus or attachments, accompanied by fever, depurulent vaginal discharge or leukorrhea, intermenstrual and postcoital bleeding, dyspareunia, dysuria and pollakiuria. The treatment of PID should provide broad-spectrum empiric antibiotic therapy for the most likely pathogens: N. gonorrhoeae and C. trachomatis, because negative screening for these organisms does not exclude infection of the upper reproductive tract. The early therapeutic measures are important in preventing long-term sequelae and the option for outpatient or hospital treatment should be based on medical judgment. Sexual partners of women with PID should be examined and treated if they had sexual relations with the patient 60 days prior to the onset of symptoms. Screening and treatment of chlamydial infection in sexually active women decreases the risk of them contracting PID. Pregnant women with suspected PID should be hospitalized to receive parenteral treatment. No differences were found in clinical manifestations of PID in women seropositive and negative for HIV. Both groups respond equally well to parenteral and oral treatments. (AU)

Tubal occlusion causing infertility due to an excessive inflammatory response in patients with predisposition for keloid formation.

Infertility is a condition that affects approximately 15-25% of couples with the desire to procreate. The integrity of the feminine reproductive tract is essential for this purpose, but the occlusion of the Fallopian tubes occurs in 12-33% of infertile women. The infection by Chlamydia trachomatis is one of the principle causes of tubal injury, which could finally lead to tubal occlusion. The tract infection has also been related to the use of intrauterine device, basically due to the fact that the insertion of the device could carry bacteria to the endometrial cavity. Keloid scars result from alterations in the normal process of wound healing, and it affects principally the population in reproductive age, maybe due to specific hormonal influence. These fibroproliferative alterations may produce significant deformations and alter organ function. The genetic factors have been studied in order to have a better understanding of the pathophysiology of keloid scarring. With these assessments, many other factors have been known to have a relationship with this abnormal healing process. This keloid scarring involves an excess in extracellular matrix production and inhibition of apoptosis, for which a several growth factors and interleukins are needed. One of the most important growth factors is IGF-1, which increases the expression of type I and III procollagen (found in the uterus); the IGF-1 receptor is overexpressed in the fibroblasts of keloids. Based on those previous observations a hypothesis that the chronic and repeated infection, and the use of IUD, generate an exaggerated inflammatory response in patients with a predisposition for keloid formation (which frequently form in childbearing age), in comparison to the patients that do not form this type of scarring, has been proposed. This makes a major frequency of adherences and finally tubal occlusion and infertility. The tendency of excessive scarring could not be exclusive of skin and generate abnormal scarring responses in feminine reproductive tract, leading to a major frequency of infertility. Thus, it could be suggested the use of other contraceptive methods and a more aggressive treatment against infections of the reproductive tract, taking in consideration the pathophysiology of keloid scar formation and its relationship with tubal occlusion.

Tubo-ovarian abscess after tubal ligation

Tubo-ovarian abscess usually results from ascending infection of the lower genital tract. In a few cases it can occur as a result of direct contamination at the time of tubal sterilization. We describe a case that presented seven years after post partum tubal sterilization, showing both acute and chronic components.(AU)

Complicaciones de la salpingoclasia por minilaparotomía en una población de pacientes / Complications of the salpingoclasia made minilaparatomy in a population of patients

Con el propósito de conocer la incidencia, diagnóstico y pronóstico de las complicaciones de la salpingoclasia por minilaparotomía, en el Hospital Maternidad Nuestra Señora de la Altagracia, Santo Domingo, República Dominicana, se realizó un estudio descriptivo, transversal y retrospectivo, durante el período comprendido entre Febrero 1993 a Febrero 1994, se estudiaron un total de 2,424 pacientes que se sometieron al procedimiento de salpingoclasia, de las cuales 64 tuvieron complicaciones para un 2.70//: la edad promedio fue entre los 25-34 años. La complicación principal fue la infección del área quirúrgica (61//); de las pacientes 17 requirieron manejo quirúrgico 47 de ellas manejo clínico. De todos los casos, sólo tuvimos uno con pronóstico reservado, los restantes un buen pronóstico. Se determina que la salpingloclasia por minilaparotomia es un procedimiento con baja incidencia de morbilidad

[Identification of Mycoplasma hominis and Ureaplasma urealyticum in patients with sterility of tubal origin]. / Identificación de Mycoplasma hominis y Ureaplasma urealiticum en pacientes con esterilidad de causa tubaria.

The peritoneal fluid of two groups of patients was cultivated; the first one was of 67 patients with tuboperitoneal problem; the second of 14 patients was the control; we founded Mollicutes in 39% of the patients of the problem group and 28% of the control group. The correlation between laparoscopic aspects with the positive Mollicutes cultures suggested the infection by Mollicutes in the tubal cause of sterility.

Antecedentes de aborto en pacientes con infertilidad secundaria

Con el objeto de determinar la relación entre el antecedente de aborto y el tipo de patología en pacientes infértiles secundarias se realizó un estudio retrospectivo en 271 pacientes con diagnóstico de infertilidad secundaria que acudieron al consultorio de Infertilidad Matrimonial del Hospital Arzobispo Loayza entre enero de 1982 y diciembre de 1989. Nuestra población de estudio fue dividida en dos subgrupos: con antecedente de aborto y sin este antecedente. Se encontró que el 63.1 por ciento de las pacientes infértiles seleccionadas tienen el antecedente de aborto teniendo igual frecuencia los abortos espontáneos como los inducidos. Se encontró mayor frecuencia de patología tubo peritoneal en las pacientes con antecedente de aborto; en el grupo de aborto inducido el 21.8 por ciento empleó métodos empíricos y el 6.1 por ciento presentó infección post aborto; la tasa de gestación post tratamiento fue el 15.9 por ciento y las principales complicaciones en el sub-grupo con antecedente de aborto fueron el embarazo ectópico y la amenaza de aborto. No se encontró relación estadísticamente significativa entre el antecedente de aborto y el desarrollo de determinado tipo de patología en las pacientes infértiles (x2: 2.17)

Abscesso pélvico em quadro de gravidez tubária rota / Pelvic abscess in ruptured ectopic pregnancy

A gravidez ectópica é o implante do ovo em qualquer tecido fora da mucosa uterina. A associaçäo de gravidez ectópica (GE) com processo inflamatório pélvico (PIP) agudo constitui raridade e estimulou a publicaçäo. Após consideraçöes históricas mostrou-se que o PIP é fator relevante no aparecimento posterior de gravidez ectópica, sendo esta sete vezes mais freqüente nas pacientes com afecçäo inflamatória pélvica. No caso aqui descrito, o PIP associado à GE deveu-se certamente à reagudizaçäo de foco inflamatório preexistente. O diagnóstico deverá ser feito considerando-se a história clínica minuciosa, a irregularidade menstrual, exame ginecológico e testes e exames laboratoriais selecionados. O tratamento, sempre que possível, deverá conservar as tubas, mesmo sem reconstruçäo imediata, sobretudo nas pacientes desejosas de gestar e sem prole

Etiology of tubal ectopic pregnancy

Fallopian tubes, removed at operation from 100 tubal ectopic pregnancies, were injected with barium sulphate/gelatine suspension and radiographs taken. Histologic sections were then examined. One hundred control tubes were treated in the same fashion, and the findings in the two groups were then compared. The tubes from 50 autopsies of infants and children were also injected with contrast medium and studied microscopically in a search for congenital lesions. Tubal diverticula were found in 49 percent of gravid tubes as compared with 11 percent of those of the control group. Diverticula were confined to the isthmus and the proximal portion of the ampulla. They were not seen in the tubes of infants and children examined at autopsy, but an etiologic relationship with chronic inflammation was suggested. On the basis of this study, it appears also that the lesions referred to as salpingitis isthmica nodosa are in fact diverticula (AU)

Tubal pregnancy in Jamaicans

A morbid anatomical study of 50 Jamaican tubal pregnancies revealed that 48 percent were associated with chronic salpingitis. Diverticula were present in the absence of inflammation. Other appearances encountered, such as trophoblastic invasion of maternal blood vessels and vascular changes, are discussed briefly. (AU)