Clinica e Investigacion en Ginecologia y Obstetricia最新文献

Background

Heavy menstrual bleeding (HMB) is a common gynecological complaint. Data on its prevalence and impact in Spain are limited.

Material and methods

A voluntary web-based survey was conducted in Spain among women aged 23–49. The survey covered several aspects of menstruation, including the characteristics and impact. The information was gathered using a semi-structured questionnaire sent by email. Results were weighted by age and geographic distribution.

Results

Of the 4478 women invited to participate, 1206 (26.9%) responded, of whom 1169 (96.9%) were menstruating. 32.7% (n = 373) said they experienced “excessive menstrual bleeding” (EMB), which was associated with increased frequency and intensity of menstrual symptoms as well as a higher percentage of women whose menstruation limited them “a lot or quite a lot” (29.1% vs. 15.7% with normal/light bleeding). Sexual intercourse was the domain most affected (59% were limited “a lot or quite a lot”). Except for family life, the impact on the domains analyzed was significantly higher among women with EMB. 67.5% of women with EMB had seen a doctor for this reason; 19.8% were receiving some type of treatment.

Conclusions

In our sample of 1206 women of childbearing age, 6.2% had HMB (EMB + “a lot or quite a lot” of limitations of daily activities). Excessive menstrual bleeding has a major impact on the daily lives of women. Two out of 3 see a doctor for this reason.

Pain is an unpleasant sensory and emotional experience. There are several ways to classify pain. It can be classified according to its temporality, distinguishing acute pain from chronic pain. Chronic pain can be classified according to its pathophysiology as nociceptive, neuropathic, or nociplastic. Most chronic pain will be classified as mixed, because it has characteristics of the three subgroups.

In patients who present chronic pain, we will frequently find peripheral and central sensitization due to a nervous system dysfunction, which, in turn, will explain why these patients have a worse prognosis and worse response to treatments provided. It is necessary to identify these sensitized patients, because they will require specific treatments with a multimodal approach.

In chronic pelvic patients, it is vitally important to perform a good and detailed anamnesis and an extended physical examination, not only focused on the gynaecological sphere, to diagnose the cause of the pain correctly.

Patients with chronic pelvic pain present highly complex pictures. Treatments proposed must be aetiological, for example, when the pain is associated with endometriosis, but we must also treat chronic pain as a disease. Treatments should be multidisciplinary and individualized for each patient and must target central sensitization.

Transvaginal ultrasound is considered the first-line imaging diagnostic test in the study of women with fibroids, adenomyosis, and ovarian and deep endometriosis. It is recommended that the ultrasound should follow the MUSA consensus for myometrial pathology, and the IDEA consensus for endometriosis.

To diagnose adenomyosis, it is necessary to identify at least one «direct» criterion (hyperechogenic buds or island or intramyometrial cysts), as well as one or several «indirect» criteria (globulous uterine morphology, «fan-shaped» shadowing, asymmetry, or non-defined junctional zone). It is recommended to specify if the adenomyosis is internal or external. Translesional vascularization of adenomyosis is different from circumferential vascularization of fibroids, of which the measurement of the 3 diameters should be reported, the echogenicity should be described, and the number and location defined according to the FIGO classification.

Ultrasound for endometriosis is performed by systematic examination of the uterus and ovaries (endometriomas), soft markers (periadnexal pseudocysts, tabicated fluid in the pouch of Douglas, fixed ovaries, tenderness-guide areas, and comma-shaped uterus), sliding sign (anterior, retrouterine, and retrocervical) and the detection and description of deep endometriotic nodules in the anterior (bladder, ureters) or posterior compartment (uterosacral ligaments, parametria, vaginal fornix, rectovaginal septum, and rectosigma).

Introduction

Pelvic pain is one of the most common pelvic floor dysfunctions in the postpartum period, depending on the degree of injury and the time at which it is assessed. The degree of involvement of a mediolateral episiotomy is similar to that of a second degree perineal tear, therefore it was decided to conduct a study to collect the degree of pain reported using the McGill Pain Questionnaire.

Material and methods

An observational, prospective longitudinal epidemiological study of dynamic cohorts was conducted among 384 women, of whom 255 had a second-degree tear and 129 had undergone an episiotomy. An assessment of the pelvic floor was carried out, together with data collection (performance or not of perineal massage, pelvic floor muscle exercises, presence of Kristeller, type of suture) as well as the degree and type of pain using the McGill Questionnaire, in the immediate puerperium, at six weeks, and six months of postpartum.

Results

In the immediate puerperium more than 50% of women reported some type of painful sensation, without finding significant differences between both cohorts. However, as the study evolved, there was a progressive decrease in pain in both cohorts. By six weeks postpartum, less than 33% of women reported a painful sensation, considered as absence of pain according to the criteria of the McGill questionnaire.

Conclusion

The presence of episiotomy or second degree perineal tear was not related to perineal pain.

Introduction

Implanon® is a subdermal contraceptive implant that is inserted on an outpatient basis. It contains 68 mg of etonogestrel, and is a long-acting reversible contraception method.

Methodology

Longitudinal and retrospective descriptive study of the patients who had Implanon® inserted in our centre between 2015 and 2016. The variables analysed were age, reasons for insertion and removal, time until removal, degree of patient satisfaction, and unwanted pregnancy during the period of use.

Results

In 97.3% of the cases, the reason for insertion was contraception, but there was one case of insertion to control heavy menstrual bleeding. The mean age of insertion was 27.2 years. The percentage continuing with the method after 3 years of follow-up was 43.6%. The most frequent reasons for requesting removal were frequent uterine bleeding (16.2%) and gestational desire (13.5%). Regarding satisfaction, overall 75.7% of the users were satisfied with the method. No pregnancy occurred in the users.

Conclusions

Implanon® is a highly effective contraceptive method, mainly used by patients around the third decade of life. The most frequent side effects observed relate to alterations in the menstrual bleeding pattern, and are among the most frequent reasons for requesting removal of the device.

Introduction

In the last few years the number of twin gestations that reach term has increased. Although vaginal delivery route has proven to be a safe alternative to caesarean section when first foetus is in cephalic presentation, available evidence on induction methods applied to this type of pregnancies is limited.

Methods

Retrospective observational study conducted in a tertiary hospital. Forty-four pregnant twins, with gestational age greater than 34 weeks, and with the first twin in cephalic presentation, who underwent induction of labour, were included. Vaginal prostaglandins (dinoprostone) were used in 17 cases and intravenous oxytocin in 27 cases, indication was randomised according to daily clinical practice. Results of both groups were compared in terms of safety and efficacy.

Results

No significant differences were found in the rate of caesarean section due to induction failure between oxytocin and prostaglandins (42.9% vs. 57.1%; P = .3). No differences were found either in terms of neonatal or maternal complications. Two pregnant women presented obstetric haemorrhage, the only maternal complication described, both in oxytocin group. Higher risk of caesarean section was found in women with BMI > 30 kg/m² (P = .001) and pre-induction Bishop's index ≤ 6 (RR: 2.06) (P = .005).

Conclusions

Both vaginal prostaglandins and intravenous oxytocin are similar in efficacy, maternal and neonatal safety when used in twin gestations. Bishop's index ≤ 6 and BMI > 30 are associated with higher probability of induction failure.

Endometriosis is a syndrome characterized by the presence of ectopic endometrial tissue. Endometrioma is its most common form of presentation, especially in moderate and severe stages of the disease.

The objective of this work was to conduct a review of the surgical treatment of endometrioma through an updated literature search, which included 56 articles.

In women with endometrioma, the ovarian reserve decreases and surgical techniques cause further reduction. Ovarian cystectomy is the technique of choice for the treatment of endometrioma. Sclerotherapy should be considered in recurrent endometriomas where ovarian preservation is relevant. Other techniques, such as CO2 laser vaporization or plasma ablation, show promising results in terms of recurrence and preservation of ovarian tissue. However, the management of endometrioma remains a challenge in reproductive medicine, where an individualized approach is essential.

Introduction

Silver-Russell syndrome is a congenital disorder that causes prenatal and postnatal growth restriction, relative macrocephaly, prominent forehead, triangular facies, clinodactyly, body asymmetry, severe feeding difficulties, and low body mass index. The most common underlying mechanisms are hypomethylation of the paternal allele at the imprinting control region 1 (ICR 1) located at 11p15.5 (seen in 50% of patients) and maternal uniparental disomy for chromosome 7 (seen in 7%–10% of patients).

Clinical findings

We present the case of a 29-year-old pregnant woman with low risk for chromosomal abnormalities at the first trimester screening. The 20-week ultrasound shows early intrauterine growth restriction (IUGR). We performed an amniocentesis with normal QF-PCR, foetal karyotype and array-CGH. Intrauterine growth restriction Type I persists at 31 + 4 weeks with estimated foetal weight, abdominal circumference, and femur length below the 1^st centile. The biparietal diameter and head circumference centiles were normal. Prominent forehead, small face, and fifth finger clinodactyly of right hand were detected. At 37 weeks, a boy weighing 1,410 g was born by caesarean section.

Diagnosis, therapeutic intervention, and results

Physical examination revealed a peculiar phenotype suggestive of Silver-Russell syndrome. The genetic study confirmed hypomethylation of ICR1 in the 11p15.5 region. Prenatal ultrasound images are shown.

Conclusions

It is important to diagnose this entity and determine genotype-phenotype correlations in order to provide the best therapeutic options, ensure adequate follow-up, and offer timely family genetic counselling.

Maternal perception of fetal movements is a subjective indicator of fetal well-being. Pregnant women's awareness of their importance remains a subject of discussion because they can increase maternal anxiety and lead to an increase in consultations about their reduction. Quantitative methods have classically been used for self-assessment, although a new qualitative method called mindfetalness has recently been proposed. Its practice has been shown to promote a better relationship with the fetus and to strengthen the maternal-fetal bond, with pregnant women preferring it to classical methods. Although consultations may increase due to decreased fetal movements, the rate of caesarean section, induction of labour, and newborns with low weight for gestational age decreases, resulting in improved maternal, fetal, and newborn management compared to not reporting fetal movements. It has been shown that pregnant women of lower sociocultural status have worse pregnancy outcomes despite its use. There may be other benefits of practicing mindfetalness such as decreased use of epidural analgesia and improved professional pregnancy care.