Clinica e Investigacion en Ginecologia y Obstetricia最新文献

Within structural intracavitary pathology, submucosal myomas are more difficult to manage than polyps. Of the submucosal myomas, type 0 and type 1 are easier to treat because their separation from the underlying myometrium is technically easier. Therefore, the most complicated hysteroscopic surgeries are currently type 2 submucosal myomectomies.

We have also begun to describe the hysteroscopic management of type 3 myomas.

With this article we propose to make a review of the most relevant points for the correct treatment of this type of myoma, reviewing its diagnosis, surgical techniques, patient preparation, and how to avoid surgical complications.

The surgical treatment of choice for endometrioma is cystectomy or endometrioma decapsulation. However, there is sufficient scientific evidence showing that this technique is associated with a decrease in ovarian reserve, either due to the removal of healthy ovarian tissue during the procedure or due to thermal damage performed during the control of haemostasis. For this reason, new surgical approaches have been described to alleviate this negative effect on ovarian reserve. The use of the CO₂ laser in gynecology has been known since the 1980s, and vaporization of the endometrioma capsule using this laser is a simple, easy-to-use, easily reproducible, and technically accessible technique. Although it was initially thought that the recurrence rate with this technique was higher, several studies show the opposite. Likewise, the damage to the ovarian reserve is less compared to decapsulation, in terms of better follicular count and antimullerian hormone level. Although the rates of spontaneous pregnancy and assisted reproductive techniques are similar, in assisted reproductive techniques patients treated with CO₂ laser vaporization have a higher follicular count and antimullerian hormone level compared to patients treated with decapsulation. To this day, the treatment of endometrioma continues to be a matter of discussion. However, the studies reviewed below favor ablative techniques in terms of better preserving ovarian reserve without increased risk of recurrence.

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.