Pre-induction cervical ripening with different initial doses of intravaginal misoprostol: time to delivery and peri-natal outcomes.

From 2016 to 2018, a total of 300 pregnant women underwent induction of labour. Those women were allocated in two groups according to the initial dose of misoprostol. Group I (150 women) received intravaginally 50 µg misoprostol followed by 25 µg every four hours, up to a maximum of four doses whereas in group II (150 women) the initial dose was 25 µg intravaginal followed by the same dose every four hours up to a maximum of four doses. Women with previous uterine scar, abnormal foetal heart rate, severe foetal malformation, foetal growth restriction or multiple pregnancy were excluded. The aim of study was to compare the effectiveness (hours until delivery) and perinatal outcomes of both schemes of cervical ripening. Initial doses of 50 µg of misoprostol reduced the time until delivery (17.65 ± 8.2 hours vs. 20.85 ± 9.3 hours; p=.007) and the need of oxytocin (34.6% vs. 46.67%; p=.046), compared to the use of 25 µg misoprostol in all doses. No differences were observed regarding perinatal outcomes.In conclusion, starting with 50 µg of misoprostol in the first dose reduced time to vaginal delivery and decreased the use of oxytocin without worse perinatal outcomes.Impact StatementWhat is already known on this subject? The rate of labour induction is increasing. Mechanical and medical methods try to establish the active phase of labour as quickly and safely as possible. For this reason, there are numerous studies assessing different protocols, dosages and indications.What do the results of this study add? Despite the numerous studies, due to ethical restrictions, it is difficult to carry out prospective studies. For this reason, studies like this help to establish the most appropriate dose of misoprostol in two of the most common indications for induction of labour. We demonstrated that increasing initial doses up to 50 mg of misoprostol are safer and more effective.What are the implications of these findings for clinical practice and/or further research? This study could be useful for future prospective and randomised studies as well for including these data in a meta-analysis. In addition, these results may update the clinical protocols and reduce hospital stay without worse perinatal outcomes.

Rotura de aneurisma de la arteria esplénica durante el embarazo / Splenic artery aneurysm rupture during pregnancy

La mayor parte de las roturas de un aneurisma esplénico ocurren en gestantes, y se asocian a una alta morbimortalidad maternofetal. El cuadro clínico típico cursa con dolor paroxístico asociado a shock hipovolémico. Presentamos un caso de rotura espontánea de un aneurisma esplénico en una gestante de 37 semanas, con el objetivo de revisar el diagnóstico de esta entidad, ya que el diagnóstico temprano de la misma es fundamental para reducir la mortalidad tanto materna como fetal. En nuestro caso el diagnóstico se realizó tras la realización de una cesárea urgente indicada por riesgo de pérdida de bienestar fetal. Durante la cesárea se objetivó hemoperitoneo intenso; tras la realización de un packing y la estabilización hemodinámica de la paciente, se realizó angio-TC, que confirmó el diagnóstico. Se realizó sección y ligadura de la arteria esplénica con esplenectomía, tras lo cual la evolución materna fue favorable. La evolución fetal fue desfavorable: nació con un alto grado de acidosis metabólica y requirió de reanimación intensa e ingreso en la UCI neonatal. El recién nacido falleció 7 días tras su nacimiento. Este caso clínico ilustra el caso típico de rotura de un aneurisma esplénico, más frecuente en el tercer trimestre de gestación debido a los cambios hemodinámicos que se producen. La sintomatología es escasa e inespecífica hasta su rotura, tras la cual se produce un cuadro de hipovolemia con afectación precoz del flujo uteroplacentario que causa la alta mortalidad fetal

Most ruptures of a splenic aneurysm occur in pregnant women, and are associated with high maternal-foetal morbidity and mortality. The typical clinical picture consists of paroxysmal pain, associated with hypovolaemic shock. The case is presented of a spontaneous rupture of a splenic aneurysm in a 37-weeks pregnant woman, with the aim of reviewing the diagnosis of this condition, since its early diagnosis is essential to reduce maternal as well as foetal mortality. In this case, the diagnosis was made after performing an urgent caesarean section, indicated due to risk of loss of foetal well-being. During the caesarean section, intense hemoperitoneum was observed. After packing and haemodynamic stabilisation of the patient, an angio-CT was performed, which confirmed the diagnosis. Splenic artery section and ligation was performed with splenectomy, after which the maternal progress was favourable. The foetal outcome was unfavourable, as it was born with a high degree of metabolic acidosis, requiring intensive resuscitation and admission to neonatal ICU. The newborn died 7 days after birth. This clinical case illustrates a typical case of a splenic aneurysm rupture, which is more frequent in the third trimester of gestation due to the haemodynamic changes that occur. The symptoms are few and non-specific until it ruptures, after which there is a hypovolaemic episode with early involvement of the uteroplacental flow that causes high foetal mortality

¿Es necesario el histerómetro y las pinzas de Pozzi para la inserción del dispositivo intrauterino? / Are hysterometers and Pozzi forceps necessary for IUD insertion?

Objetivo: Exponer la técnica de inserción del DIU que denominamos de «mínima manipulación» y analizar los resultados obtenidos con la misma. Metodología: Se incluyen un total de 442 pacientes que demandaron DIU como método anticonceptivo entre 2010 y 2014. A todas se insertó un DIU con la técnica de «mínima manipulación» que consta de los siguientes pasos: 1) ambiente confortable y apoyo psicológico por parte de enfermera cualificada; 2) ecografía transvaginal para definir posición, tamaño y grado de flexión del útero; 3) especuloscopia, y 4) inserción suave y cuidadosa del DIU siguiendo la dirección establecida por la ecografía. Resultados: El dolor percibido por las pacientes a la inserción, dentro de la Escala Visual Analógica Estándar (VAS), fue de un 3,15 de media, siendo superior en nulíparas. Tuvimos una perforación. Cuatro pacientes experimentaron reacción vagal leve. Se precisó recurrir al tenáculo en el 5% de los casos. En 2 casos no se consiguió la inserción. Conclusiones: La técnica descrita y empleada para la colocación del DIU, denominada como de «mínima manipulación», tiene una alta efectividad de inserción y una valoración aceptable por parte de las usuarias

Objective: To describe the IUD insertion technique that we call 'minimal handling' and analyse the results obtained using this technique. Methodology: We included a total of 442 patients, who requested an IUD for contraception between 2010 and 2014. We inserted an IUD in all patients using the 'minimal handling' technique, which consisted of the following steps: 1) Comfortable environment and psychological support from the qualified nurse. 2) Transvaginal ultrasound to define the position, size, and degree of flexion of the uterus. 3) Speculoscopy. 4) Smooth and careful insertion of the IUD following the direction established by the ultrasound. Results: The pain perceived by the patients upon insertion using the Standard Visual Analogue Scale (VAS) was a mean of 3.15, being higher in nulliparous patients. We had one perforation. Four patients experienced a mild vasovagal response. It was necessary to use the tenaculum in 5% of cases. In two cases, insertion was not achieved. Conclusions: The technique described and used for putting the IUD in place, known as the 'minimal handling' method, is highly effective as an insertion technique and is evaluated as acceptable by users