Thromboprophylaxis in gynecologic cancer surgery: Is extended prophylaxis with low molecular weight heparin justified?

OBJECTIVE: Evidence on the optimal duration of thromboprophylaxis with low molecular weight heparin after gynecologic cancer surgery is scarce and the benefits of extended prophylaxis have not been validated specifically in these patients. The aim of this study is to assess the efficacy and safety of postoperative venous thromboembolism (VTE) prophylaxis with enoxaparin 40 mg for 28 days, as recommended by international guidelines, compared to 7 days in patients undergoing surgery for gynecologic cancer. STUDY DESIGN: Prospective cohort study compared to a historic cohort of women who underwent surgery for gynecologic cancer in our center between 2004 and 2014. Pre- and postoperative screening with a routine duplex scan was done in the prospective cohort. Comparative analysis of comorbidity, surgical technique and incidence of VTE, as well as prognostic factors of events and mortality. RESULTS: N:571 patients (28 days: 207, 7 days: 364). No significant differences were identified between groups in regard to the factors related to VTE in our series. There were no differences in VTE incidence between groups after one month (1.9% vs 1.4%; p = 0.729), 90 days (2.4% vs 2.5%; p > 0.99) or during follow-up (Breslow p = 0.156). No deaths due to VTE at 90 days were recorded. Only one case of asymptomatic DVT was identified in the screening with duplex. The incidence of postoperative bleeding was similar in both groups (0.5% vs 2.2%; p = 0.166). The presence of a history of VTE was the only independent risk factor for VTE after one month (OR 14.31 CI 95% 2.67-76.87; p = 0.002) and 90 days (OR 8.27 CI 95% 1.65-41.45; p = 0.010). No differences were identified regarding age, other comorbidities, type of tumor, stage, surgical approach, reintervention or adjuvant therapy in the multivariate analysis. CONCLUSION: Extended prophylaxis for 28 days with enoxaparin did not improve the rates of VTE following gynecologic oncological surgery in our series compared to the 7-day therapy, although neither was this extended duration associated with adverse events or mortality.

Gestación heterotópica accidentada / Ruptured heterotopic pregnancy

La gestación heterotópica es una circunstancia rara y de difícil diagnóstico, puesto que en ciclos de concepción natural su incidencia es muy baja. Por ello es importante descartar su diagnóstico en aquellas pacientes con una gestación intrauterina y dolor abdominal y hemoperitoneo. Presentamos el caso clínico de una primigesta de 35 años, sin antecedentes, con gestación actual espontánea, que consultó por metrorragia. Tras la sospecha de gestación heterotópica, se realizaron una salpingectomía laparoscópica y un legrado evacuador del aborto en curso. La anatomía patológica confirmó el diagnóstico (AU)

Heterotopic pregnancy is a rare event. Because the incidence is very low in natural conception cycles, this entity is difficult to diagnose. Therefore, it is important to rule out this diagnosis in patients with an intrauterine pregnancy, abdominal pain and hemoperitoneum. We report the case of a 35-year-old woman with no relevant medical history and a spontaneous pregnancy, who presented with metrorrhagia. Due to suspicion of a heterotopic pregnancy, laparoscopic salpingectomy and curettage of the abortion in progress were performed. The diagnosis was confirmed by pathological analysis (AU)

Uso de misoprostol en el tratamiento de abortos diferidos del primer trimestre / Misoprostol use in the treatment of early missed abortions

Objetivo: Evaluar los resultados de nuestra experiencia con el tratamiento de misoprostol sublingual como alternativa en el tratamiento del aborto diferido precoz. Material y métodos: Estudio retrospectivo descriptivo que incluyó a 252 pacientes diagnosticadas de aborto diferido en el primer trimestre en el Consorcio Sanitario de la Anoia, desde marzo de 2010 a diciembre de 2012, a las que se les realizó previo consentimiento, protocolo de tratamiento de misoprostol sublingual. Resultados: La efectividad del tratamiento con misoprostol fue del 84,77% (206 casos). En 143 (58,85%) pacientes se consiguió con la primera dosis y en 63 (25,92%) pacientes con la segunda. En 37 (15,23%) pacientes se realizó legrado uterino por inefectividad del tratamiento con misoprostol, habiendo realizado las 2 dosis establecidas por protocolo en 29 casos y una sola dosis en 8. En la valoración de la satisfacción global de la paciente hacia el tratamiento médico se obtuvo una media de 7,5 en las 235 pacientes en las que se siguió el protocolo. Conclusión: El tratamiento médico es una alternativa menos agresiva que la cirugía, con tasas de éxito que se aproximan al 90% y efectos secundarios leves, controlables con medicación adicional; además de presentar un alto grado de satisfacción global y un menor coste que la cirugía (AU)

Objective: To evaluate the results of our experience with sublingual misoprostol as an alternative treatment for early missed abortions. Material and methods: A retrospective study was carried out at the Consorcio Sanitario Anoia between March 2010 and December 2012 in 252 patients diagnosed with missed first-trimester abortions, who were treated with sublingual misoprostol, with prior consent. Results: The effectiveness of misoprostol therapy was 84.77% (206 cases). In 143 cases (58.85%) the result was achieved with the first dose and in 63 cases (25.92%) with the second. In 37 cases (15.23%), misoprostol therapy (with a single dose in 8 cases and following the protocol with a double dose in 29 cases) was ineffective and uterine curettage was required. Overall patient satisfaction with medical treatment scored an average of 7.5 points among the 235 patients who were treated following the protocol. Conclusion: Medical treatment is less aggressive than surgery, with success rates approaching 90%. Minor side effects are manageable with additional medication. Overall patient satisfaction was high and the costs were lower than for surgical treatment (AU)

Carcinoma basocelular de vulva / Basal cell carcinoma of the vulva

El carcinoma basocelular de vulva es una entidad muy poco frecuente, puesto que este tipo de neoplasia cutánea tiene relación directa con las áreas de piel fotoexpuestas. Suele presentarse en pacientes posmenopáusicas y la localización más frecuente de la región perineal es en los labios mayores. En este artículo, se presenta un caso de carcinoma basocelular nodular de vulva en una paciente premenopáusica (AU)

Basal cell carcinoma of the vulva is a rare entity because this type of neoplasm is directly related to sun-exposed skin areas. It usually develops in postmenopausal patients and the most common location of the perineal region is in the labia. This article presents a case of nodular basal cell carcinoma of the vulva in a premenopausal woman (AU)

Opciones terapéuticas en el embarazo intersticial / Therapeutic options in interstitial pregnancy

El embarazo cornual es un hecho muy poco frecuente, con una incidencia entre un 2-4% de las gestaciones ectópicas. Al igual que el embarazo tubárico, las opciones terapéuticas incluyen la cirugía, la terapia médica o la combinación de ambas. Actualmente, existen otras opciones terapéuticas también eficaces. Presentamos un caso de gestación cornual tratado a través de resección histeroscópica con posterior revisión laparoscópica como opción terapéutica eficaz (AU)

Cornual pregnancy is very rare, with an incidence of 2-4% of ectopic pregnancies. As with tubal pregnancy, treatment options include surgery, medical therapy or a combination of both. Currently, there are also other treatment options that are effective. We report a case of cornual pregnancy treated with hysteroscopic resection followed by laparoscopic review, which can be an effective treatment option (AU)