Revista Peruana de Ginecología y Obstetricia

Association between negative antithyroid peroxidase antibodies subclinical hypothyroidism and adverse perinatal outcomes diagnosed with different criteria in the third trimester of pregnancy

RESUMEN Antecedentes. El efecto del hipotiroidismo subclínico (HSC) en los resultados perinatales adversos no está claro, y los valores de referencia de la hormona tiroestimulante (TSH) en el embarazo son controvertidos. Objetivo. Evaluar los efectos del HSC negativo para los anticuerpos de la peroxidasa tiroidea (TPOAbs) sobre los resultados perinatales según los diferentes valores de referencia de la TSH. Métodos. Un total de 554 mujeres embarazadas, incluyendo 509 eutiroideas y 45 gestantes hipotiroideas subclínicas (TSH > 3 mIU/L), fueron incluidas en este estudio prospectivo de casos y controles. Todas las gestantes estaban en el tercer trimestre y eran negativas a los TPOAbs. Las funciones tiroideas fueron evaluadas utilizando los valores de referencia específicos para el trimestre recomendados por el Colegio Americano de Obstetricia y Ginecología (ACOG) (TSH > 3 mIU/L) y la Asociación Americana de Tiroides (ATA) (TSH > 4 mIU/L). Resultados. La mortalidad neonatal en el hipotiroidismo subclínico con un límite superior de TSH de 4 mIU/L fue significativamente menor que en el grupo eutiroideo (2 (0,4%) frente a 1 (4,5%); p=0,009). No hubo diferencias significativas en resultados maternos y perinatales adversos en las gestantes con HSC y eutiroideas en ambos valores de referencia de la TSH. No hubo correlación significativa entre los valores de TSH y las semanas de parto de las gestantes con parto prematuro (r=0,169, p=0,146). Conclusiones. En este estudio, utilizando los diferentes valores basales de TSH recomendados por las directrices del ACOG de 2020 y de la ATA de 2017 en el tercer trimestre del embarazo para el diagnóstico de hipotiroidismo subclínico, no hubo una relación significativa entre los casos de hipotiroidismo subclínico con TPOAbs negativos y los resultados perinatales adversos.

ABSTRACT Background: The effect of subclinical hypothyroidism (SCH) on adverse perinatal outcomes is unclear, and thyroid-stimulating hormone (TSH) reference values in pregnancy are controversial. Objective: To evaluate the effects of thyroid peroxidase antibody (TPOAbs) negative SCH on perinatal outcomes according to the different TSH reference values. Methods: A total of 554 pregnant women, including 509 euthyroid and 45 subclinical hypothyroid (TSH > 3 mIU/L) pregnant women, were included in this prospective case-controlled study. All pregnant women were in the third trimester and were TPOAbs negative. Thyroid functions were evaluated using trimester-specific reference values recommended by the American College of Obstetrics and Gynecology (ACOG) (TSH > 3 mIU/L) and the American Thyroid Association (ATA) (TSH > 4 mIU/L) guidelines. Results: Neonatal mortality in subclinical hypothyroidism with a TSH upper limit of 4 mIU/L was significantly lower than in the euthyroid group (2 (0.4%) vs 1 (4.5%); p=0.009). There was no significant difference in terms of adverse maternal and perinatal outcomes in SCH and euthyroid pregnant women in both TSH reference values. There was no significant correlation between TSH values and delivery weeks of pregnant women with preterm delivery (r=0.169, p=0.146). Conclusions: In this study, using different baseline TSH values recommended by the 2020 ACOG and 2017 ATA guidelines in the third trimester of pregnancy for the diagnosis of subclinical hypothyroidism, it was shown that there was no significant relationship between cases of subclinical hypothyroidism with negative TPOAbs and adverse perinatal outcomes.

The association of bile acid and thyroid hormone levels in intrahepatic colestasis of pregnancy

RESUMEN La colestasis intrahepática del embarazo (CIE) conduce a resultados perinatales adversos y estos resultados se ven afectados por los niveles elevados de ácido biliar total (ABT). Los estudios han demostrado que las hormonas tiroideas regulan el metabolismo de los ácidos biliares. Sin embargo, pocos estudios han evaluado el papel de las hormonas tiroideas en la CIE. Objetivo: Evaluar la función tiroidea junto con los niveles de ABT en la CIE. Métodos. En este estudio retrospectivo, se evaluaron 252 mujeres embarazadas, incluyendo 126 CIE y 126 controles. Se determinaron los niveles de ABT, hormona estimulante de la tiroides (TSH) y tiroxina libre (fT4) del tercer trimestre de todas las embarazadas. Se examinó la correlación entre los niveles de ABT, fT4 y TSH. Además, se estudiaron los resultados perinatales de ambos grupos. Resultados. Los niveles de fT4 fueron significativamente mayores en la CIE. También hubo una correlación positiva entre los niveles de fT4 y ABT. Los niveles de TSH fueron similares en ambos grupos y no hubo una correlación significativa con los niveles de ABT. No hubo diferencias significativas entre los dos grupos en cuanto a enfermedades tiroideas en el tercer trimestre. Conclusiones. Un mayor nivel de fT4 se asoció a un mayor nivel de ABT y el nivel de fT4 se asoció a un mayor riesgo de CIE y a la gravedad de la CIE, pero el nivel de TSH no se asoció a un mayor riesgo de ABT y de CIE.

ABSTRACT Intrahepatic cholestasis of pregnancy (ICP) leads to adverse perinatal outcomes and these outcomes are affected by high total bile acid (TBA) levels. Studies have shown that thyroid hormones regulate bile acid metabolism. However, few studies have evaluated the role of thyroid hormones in ICP. Objective: To evaluate thyroid function along with TBA levels in ICP. Methods: In this retrospective study, 252 pregnant women, including 126 ICP and 126 controls, were evaluated. Third trimester TBA, thyroid-stimulating hormone (TSH), and free thyroxine (fT4) levels of all pregnant women were assessed. Correlation between TBA and fT4, TSH levels were examined. In addition, the perinatal outcomes of both groups were determined. Results: fT4 levels were significantly higher in ICP. There was also a positive correlation between fT4 and TBA levels. TSH levels were similar in both groups and there was no significant correlation with TBA levels. There was no significant difference between the two groups in thyroid diseases in the third trimester. Conclusions: Higher fT4 level was associated with higher TBA level and fT4 level was associated with higher ICP risk and ICP severity, but TSH level was not associated with higher TBA and higher ICP risk.

Cervical vascularization low he in the prediction of imminent preterm labor

RESUMEN Objetivo. Establecer la utilidad de los índices de vascularización cervical en la predicción de parto pretérmino inminente. Diseño. Estudio de casos-controles. Institución. Hospital Central "Dr. Urquinaona", Maracaibo, Venezuela. Participantes. Pacientes con parto pretérmino en los siguientes 7 días (grupo A) y embarazadas con parto pretérmino más allá de los 7 días (grupo B). Métodos. Las embarazadas fueron evaluadas utilizando ecografía transvaginal y seguidas hasta el parto. Principales medidas de resultado. Características generales, índices de vascularización cervical (índice de vascularización, índice de flujo e índice de vascularización / flujo), parto pretérmino inminente y eficacia pronóstica. Resultados. Fueron incluidas 350 pacientes, 75 mujeres presentaron parto pretérmino inminente (grupo A) y 251 pacientes fueron consideradas como controles (grupo B). Las pacientes del grupo A tuvieron valores significativamente más bajos del índice de vascularización e índice de flujo comparado con el grupo B (p = 0,0122 y p < 0,0001, respectivamente). Las pacientes del grupo B presentaron valores significativamente más altos de índice de vascularización / flujo comparadas con las pacientes del grupo A (p = 0,0103). Los tres índices y la combinación de estos no mostraron capacidad de discriminación de parto pretérmino inminente. Conclusiones. Las pacientes con parto pretérmino inminente presentan diferencias significativas en los índices de vascularización comparado con las pacientes que presentan parto pretérmino más allá de los 7 días de la evaluación ecográfica. Sin embargo, no son útiles en la predicción del parto pretérmino inminente.

ABSTRACT Objective: To establish the usefulness of cervical vascularization low he in the prediction of impending preterm labor. Design: Case-control study. Institution: “Dr. Urquinaona” Central Hospital, Maracaibo, Venezuela. Participants: Patients with preterm delivery within 7 days (group A) and pregnant women with preterm delivery beyond 7 days (group B). Methods: Pregnant women were evaluated using transvaginal ultrasound and followed until delivery. Main outcome measures: General characteristics, cervical vascularity low he (vascularity index, low index and vascularity / low index), impending preterm delivery, and prognostic efficacy. Results: A total of 350 patients were included, 75 women presented imminent preterm labor (group A) and 251 patients were considered as controls (group B). Patients in group A had significantly lower values of vascularization index and low index compared to group B (p = 0.0122 and p < 0.0001, respectively). Patients in group B had significantly higher values of vascularization / low index compared to patients in group A (p = 0.0103). The three low he and the combination of these did not show the ability to discriminate imminent preterm labor. Conclusions: Patients with imminent preterm labor showed significant differences in the vascularization low he compared to patients presenting preterm labor beyond 7 days of ultrasound evaluation. However, they are not useful in predicting impending preterm labor.

Women’s involvement in medical decisionmaking during pregnancy and childbirth

RESUMEN Introducción: Potenciar la participación de las mujeres durante el embarazo y el parto se alinea con el llamado de la Organización Mundial de la Salud y se vincula con efectos en la satisfacción usuaria, resultados clínicos de salud y una mejor gestión de los prestadores de salud. Objetivo : Descubrir las necesidades de participación en la toma de decisiones de las mujeres durante el proceso del embarazo y parto. Método : Análisis secundario de un estudio cualitativo descriptivo con mujeres hospitalizadas del servicio de puerperio de dos hospitales en Santiago de Chile. El análisis de los datos se realizó utilizando el método propuesto por la Grounded Theory. Resultados : Participaron doce mujeres en dos grupos focales. Del análisis relacional se desprende que la participación en el proceso reproductivo es interferida por dos grupos de factores vinculados a significados culturales y a la vulneración de los derechos de las mujeres. Conclusiones. La participación de las mujeres en las decisiones clínicas durante el proceso de embarazo y parto es aún escasa y el poder sigue manteniéndose en los profesionales de la salud, perpetuándose prácticas de violencia institucional. Para avanzar en una práctica obstétrica centrada en las mujeres, es importante reconocer el papel activo que ellas quieren y pueden cumplir para vivir una experiencia positiva y satisfactoria.

ABSTRACT Introduction : Enhancing women's participation during pregnancy and childbirth is in line with the call of the World Health Organization and is linked to effects on user satisfaction, clinical health outcomes and better management of health care providers. Objective : To discover women's needs for participation in decision making during pregnancy and childbirth. Methods : Secondary analysis of a descriptive qualitative study with hospitalized women from the puerperium service of two hospitals in Santiago, Chile. The data analysis was carried out using the method proposed by Grounded Theory. Results : Twelve women participated in two focus groups. The relational analysis showed that participation in the reproductive process is interfered by two groups of factors linked to cultural meanings and to the violation of women's rights. Conclusions: Women's participation in clinical decisions during pregnancy and childbirth is still scarce and power is still held by health professionals, perpetuating practices of institutional violence. To advance in obstetric practice centered on women, it is important to recognize the active role that women want and can play in order to have a positive and satisfactory experience.

Usefulness of intraoperative sentinel node palpation in breast cancer: a cross-sectional study

RESUMEN Objetivo. Determinar la utilidad de la palpación intraoperatoria y las características macroscópicas del ganglio centinela en cáncer de mama en predecir su afectación en el examen microscópico. Métodos. Estudio descriptivo de corte transversal con análisis secundario del registro personal de un cirujano entre el 1 de mayo de 2018 y el 31 de octubre de 2020, en un centro de referencia en Medellín, Colombia. Se incluyeron mujeres con cáncer de mama sin afectación clínica axilar llevadas a cirugía para biopsia de ganglio centinela. Se recopilaron los datos demográficos, clínicos y paraclínicos que fueron analizados utilizando estadística descriptiva. Resultados. De 355 pacientes sometidas a biopsia de ganglio centinela por cáncer de mama, la tasa de detección de ganglio centinela fue del 98,3 % (n= 347). Se encontró mayor probabilidad de estar afectado en las pacientes a quienes se les realizaba una mastectomía (ORa= 4,61; IC95%: 1,07 a 19,81), cuando la consistencia del ganglio era dura o semidura (ORa= 3,90; IC 95%: 2,00 a 7,62) y cuando la forma del ganglio era lobulada o irregular (ORa= 12,98; IC 95%: 2,10 a 80,19). Por el contrario, era menos probable que estuviera afectado cuando había recibido quimioterapia neoadyuvante (ORa= 0,11; IC 95%: 0,02 a 0,57). Conclusión. La evaluación de las características macroscópicas durante la técnica del ganglio centinela para la estadificación axilar puede predecir su afectación en el examen microscópico.

ABSTRACT Objective: To determine the usefulness of intraoperative palpation and macroscopic characteristics of the sentinel lymph node in breast cancer in predicting its involvement on microscopic examination. Methods: Descriptive cross-sectional study with secondary analysis of a surgeon's personal registry between May 1, 2018, and October 31, 2020, at a referral center in Medellin, Colombia. Women with breast cancer without clinical axillary involvement taken to surgery for sentinel node biopsy were included. Demographic, clinical and paraclinical data were collected and analyzed using descriptive statistics. Results: Of 355 patients who underwent sentinel node biopsy for breast cancer, the sentinel node detection rate was 98.3 % (n= 347). A higher probability of being affected was found in patients who underwent mastectomy (ORa= 4.61; 95% CI: 1.07-19.81), when the consistency of the node was hard or semi-hard (ORa= 3.90; 95% CI: 2.00-7.62) and when the shape of the node was lobulated or irregular (ORa= 12.98; 95% CI: 2.10-80.19). In contrast, it was less likely to be affected when it had received neoadjuvant chemotherapy (ORa= 0.11; 95% CI: 0.02-0.57). Conclusion: The evaluation of macroscopic features during sentinel node technique for axillary staging can predict its involvement on microscopic examination.

The coronavirus conundrum The end of the COVID-19 pandemic? The woman, the pregnant woman and the fetus Vaccines Future

RESUMEN El Director General de la OMS Tedros Adhanom Ghebreyesus ha dicho recientemente que ‘El fin de la pandemia está cerca. Todavía no hemos llegado, pero el final está a la vista’. Y el presidente de los EE. UU. Joe Biden, con alrededor de 400 muertes por día en los EE. UU., ha repetido dicha aseveración. Por lo que podemos leer en la literatura, aún no estaríamos en tal situación y pudiera haber un buen trecho por recorrer. Si bien se conoce más acerca del virus y su capacidad de transformación en variantes y subvariantes de manera de ingresar con más facilidad al huésped, algunas de estas transformaciones son motivo de preocupación. Hacemos una revisión somera sobre lo aprendido sobre la morbimortalidad por el SARS-CoV-2, cómo ha empeorado la salud de las mujeres, algunas alteraciones en el esperma, las defensas ante el virus, las reinfecciones, su accionar malsano sobre la gestante, el feto y el neonato, las vacunas y refuerzos y una visión de lo que nos espera.

ABSTRACT WHO Director General Tedros Adhanom Ghebreyesus has recently said that 'The end of the pandemic is near. We are not there yet, but the end is in sight'. And U.S. President Joe Biden, with about 400 deaths per day in the U.S., has repeated that assertion. From what we can read in the literature, we are not there yet and there may be a long way to go. Although more is known about the virus and its ability to transform into variants and subvariants in order to enter the host more easily, some of these transformations are cause for concern. We make a brief review of what we have learned about morbidity and mortality due to SARS-CoV-2, how women's health has worsened, some alterations in sperm, defenses against the virus, reinfections, its unhealthy action on the pregnant woman, the fetus and the newborn, vaccines and boosters, and a vision of what lies ahead.

Sacral cutaneous appendage associated with lipoma of the filum terminale and anchored medulla: a case of prenatal diagnosis

RESUMEN Los disrafismos espinales cerrados tienen una prevalencia aún desconocida e involucran una gran variedad de formas. El lipoma del filum terminal es considerado dentro de los lipomas espinales y suele asociarse a médula anclada. Los estigmas cutáneos lumbosacros no siempre son indicadores de disrafismo espinal cerrado. Reportamos un caso de diagnóstico prenatal de apéndice cutáneo sacro con sospecha de médula anclada, confirmado al nacer como lipoma del filum terminal con médula anclada.

ABSTRACT Closed spinal dysraphisms have a still unknown prevalence and involve a wide variety of forms. Lipoma of the filum terminale is considered within spinal lipomas and is usually associated with tethered medulla. Lumbosacral cutaneous stigmata are not always indicative of closed spinal dysraphism. We report a case of prenatal diagnosis of sacral cutaneous appendage with suspected tethered cord, confirmed at birth as lipoma of the filum terminale with tethered cord.

Fetoscopic surgery in amniotic band syndrome: report of the first successful case in Peru with postnatal outcome at 6 and 12 months of life

RESUMEN El síndrome de banda amniótica (SBA) o complejo de disrupción de banda amniótica es aquella malformación congénita que ocurre como consecuencia de bridas amnióticas de etiología heterogénea, patogénesis que involucra una serie de manifestaciones clínicas fetales, tales como constricción, amputación y múltiples defectos craneofaciales, viscerales y de la pared del cuerpo. La prevalencia estimada de SBA oscila entre 1:15,000 y 1:1,200 nacidos vivos. Afecta a ambos sexos por igual. El diagnóstico prenatal puede sospecharse tan pronto como el primer trimestre tardío, cuando las imágenes por ultrasonido detectan anillos de constricción, amputaciones de extremidades y/o defectos craneofaciales. La terapia prenatal puede ofrecer una alternativa de tratamiento con la liberación de anillos de constricción bajo fetoscopia en aquellos fetos que se verían beneficiados con el procedimiento.

ABSTRACT Amniotic band syndrome (ABS) or amniotic band disruption complex is a congenital malformation that occurs because of amniotic flanges of heterogeneous etiology, a pathogenesis that involves a series of fetal clinical manifestations, such as constriction, amputation, and multiple craniofacial, visceral and wall defects. The estimated prevalence of ABS ranges from 1:15.000 to 1:1.200 liveborn. It affects both sexes equally. Prenatal diagnosis may be suspected as early as the late first trimester when ultrasound imaging detects constriction rings, limb amputations and/or craniofacial defects. Prenatal therapy may offer an alternative treatment with release of constriction rings through fetoscopy in those fetuses that would benefit from the procedure.

Management of monochorionic monoamniotic twin pregnancy: literature review and case report

RESUMEN A propósito de la presentación de un caso de embarazo gemelar monocoriónico monoamniótico, se revisó la literatura sobre su diagnóstico y manejo mediante búsqueda electrónica en la base de datos de Medline, OVID, Cochrane y PubMed entre los años 1966 y 2019. Las palabras clave utilizadas en la indagación fueron: embarazo, gemelos, monoamniótico, enredamiento de cordones. Existe un riesgo alto de muerte fetal súbita en gemelos monoamnióticos causado por el enredamiento de los cordones umbilicales, por lo que el diagnóstico oportuno de la corionicidad y amnionicidad en el embarazo gemelar mediante ecografía puede dar la pauta para una vigilancia fetal estrecha y mejorar así el resultado obstétrico.

ABSTRACT In view of the presentation of a case of monochorionic monoamniotic twin pregnancy, the literature on its diagnosis and management was reviewed by electronic search in the Medline, OVID, Cochrane, and PubMed databases between 1966 and 2019. The key words used in the inquiry were: pregnancy, twins, monoamniotic, cord entanglement. There is a high risk of sudden fetal death in monoamniotic twins caused by entanglement of the umbilical cords, so timely diagnosis of chorionicity and amnionicity in twin pregnancy by ultrasonography may provide guidance for close fetal surveillance and thus improve obstetric outcome.

Strategies to improve reproductive outcomes after empty follicle syndrome: a case report

RESUMEN El síndrome del folículo vacío (SFV) es el fracaso total para recuperar los ovocitos después de la estimulación ovárica, a pesar de un desarrollo folicular aparentemente normal y una esteroidogénesis folicular adecuada. Se han descrito dos variantes de SFV: la forma genuina, que ocurre en presencia de niveles adecuados de hCGβ circulante o de LH en el momento de la aspiración de ovocitos, y la forma 'falsa', que se asocia a niveles séricos de hCG/LH por debajo de un umbral crítico. En nuestra paciente, tras un protocolo aceptado de estimulación ovárica con gonadotropina menopáusica humana y folitropina alfa y posterior maduración folicular con coriogonadotropina alfa no se obtuvieron cúmulos ovocitarios en la punción ecoguiada, con lo que se trató de emplear otras estrategias encaminadas a corregir esta situación. El tratamiento y el pronóstico de estas pacientes aún no se conocen bien. Se necesitan grandes estudios multicéntricos y revisiones sistemáticas para aumentar la comprensión del SFV y así, su manejo, diseñando mejores estrategias como tratamos de hacer con nuestra paciente con el empleo de doble descarga para maduración ovocitaria.

ABSTRACT Empty follicle syndrome (EFS) is the complete failure to retrieve oocytes after ovarian stimulation, despite apparently normal follicular development and adequate follicular steroidogenesis. Two variants of EFS have been described: the genuine form, which occurs in the presence of adequate circulating βhCG or LH levels at the time of oocyte aspiration, and the 'false' form, which is associated with serum hCG/ LH levels below a critical threshold. In our patient, after an accepted protocol of ovarian stimulation with human menopausal gonadotropin and follitropin alfa and subsequent follicular maturation with choriogonadotropin alfa, no oocyte clusters were obtained in the ultrasound-guided puncture, so an attempt was made to use other strategies aimed at correcting this situation. The treatment and prognosis of these patients are still poorly understood. Large multicenter studies and systematic reviews are needed to increase understanding of EFS and thus its management, designing better strategies as we tried to do with our patient with the use of double discharge for oocyte maturation.

Continuous glucose monitoring during gestation in patients with pregestational type 2 diabetes mellitus

RESUMEN La diabetes pregestacional requiere un control glicémico estricto durante el embarazo. Los dispositivos de monitoreo continuo de glucosa (MCG) miden niveles de glucosa intersticial sin necesidad de punción capilar. Se estudió 4 gestantes con diabetes mellitus tipo 2 pregestacional con la ayuda del MCG durante 2 semanas de su gestación. Ellas tuvieron sesiones nutricionales semanales y controles médicos con un endocrinólogo. El promedio de nivel de glucosa osciló entre 82 y 171 mg/dL. El MCG permitió cambios tempranos en el tratamiento de una paciente con hipoglicemia. Todas las pacientes manifestaron que el MCG les ayudó en la selección de sus alimentos. En conclusión, el MCG ayudó en el reconocimiento de carbohidratos y en el reajuste del tratamiento. El MCG tuvo buena aceptación de su uso.

ABSTRACT Pregestational diabetes requires strict glycemic control during pregnancy. Continuous glucose monitoring (CGM) devices measure interstitial glucose levels without the need for capillary puncture. Four pregnant women with pregestational type 2 diabetes mellitus were studied with the aid of CGM during 2 weeks of their gestation. They had weekly nutritional sessions and medical controls with an endocrinologist. The average glucose level ranged from 82 to 171 mg/dL. The CGM allowed early changes in the treatment of one patient with hypoglycemia. All patients stated that the GCM helped them in their food selection. In conclusion, the GCM helped in carbohydrate recognition and treatment readjustment. The CGM was well accepted for use.

Miller-Fisher syndrome during pregnancy

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ABSTRACT Miller-Fisher syndrome is a rare, acute, autoimmune, demyelinating disorder which is considered a variant of Guillain-Barré syndrome. The pathologic mechanism is unclear, but acute demyelinating polyneuropathies may be triggered by bacterial or viral infections, major surgical interventions, or vaccination. Pregnancy may be a trigger of the immune response causing the onset of the syndrome. Miller-Fisher syndrome is characterized by acute onset, with predominant involvement of the facial and cranial nerves resulting in ophthalmoparesis, ataxia, and areflexia/hyporeflexia. Diagnosis is based on clinical suspicion together with the determination of specific ganglioside antibodies and other laboratory and imaging tests. Treatment consists of intravenous immunoglobulin and plasmapheresis, together with supportive measures. There are few reports of the syndrome occurring in pregnant women. A case of Miller-Fisher syndrome during pregnancy is presented.

INTRODUCTION Miller-Fisher syndrome (MFS) is a rare disorder that is characterized by acute onset of ophthalmoparesis, ataxia and hyporeflexia / areflexia(1). It was recognized 60 years ago as a variant of Guillain-Barré syndrome (GBS). The annual incidence is 0.09 per 100,000 persons and affects more males than females with a 2:1 ratio(2). GBS usually follows Campylobacter jenuni, cytomegalovirus, Epstein-Barr and influenza virus infections or secondary to major surgery, pregnancy, or vaccination(3,4). MFS accounts for 5%-10% of GBS cases and may have a major autoimmune component due to the presence of anti-ganglioside antibodies. During the acute phase of the disease, these antibodies have a diagnostic sensitivity and specificity of 92% and 97%, respectively(5). MFS during pregnancy is rare and there are only reports of 5 cases in pregnant women. A case of Miller-Fisher syndrome during pregnancy is presented. CLINICAL CASE The patient was 16 years old, primigravida of 20 weeks, who was referred for presenting nausea and incoercible vomiting of five days of evolution, accompanied by double vision, generalized weakness, ataxia, difficulty walking, dysphonia for 2 days. She denied a history of respiratory and/or gastrointestinal infections or neurological diseases during pregnancy. She also denied any important family history. On physical examination the patient was in fair condition, afebrile and slightly dehydrated. Vital signs were blood pressure 145/82 mmHg, heart rate 88 beats per minute and temperature 36.9°C. She was anxious and uncomfortable on questioning but was oriented in all three spheres. Higher mental functions were preserved with coherent and congruent language, preserved anterograde and retrograde memory. Bilateral ophthalmoparesis with non-fluctuating deconjugate eye deviation was noted, with restriction of left eye abduction and limitation of bilateral eye movement in all other directions, with no evidence of ptosis and nystagmus. Pupils were isometric, mydriatic and normoreactive with normal fundus. No evidence of alteration of the rest of the cranial nerves was found. In addition, proximal predominant quadriparesis was found with diminished osteotendinous reflexes (1/4) in all four extremities, bilateral negative Babinski with absence of abnormal movements and signs of meningeal irritation. Proprioception was impaired, but vibration and temperature perception were normal. Ataxia was prominent in the lower extremities during standing and walking, despite preservation of motor strength. Obstetric examination showed single, live fetus, with uterine height of 21 centimeters compatible with gestational age, and fetal heart rate of 149 beats per minute, without evidence of cervical changes and/or loss of amniotic fluid. Hematology, liver and renal function, coagulation profile, urine test and electrolytes were within normal limits. Computed tomography and magnetic resonance imaging, computed tomography angiography and magnetic resonance venogram showed no abnormalities. Electromyography showed evidence of severe sensory-motor demyelinating polyneuropathy, length-dependent and symmetrical, with greater involvement of the lower extremities, but without signs of presynaptic junction disorder. Cerebrospinal fluid analysis obtained by lumbar puncture denoted absence of albumin-cytologic dissociation with protein concentrations of 0.60 g/L and glucose of 70 mg/dL (central glucose of 81 mg/dL). Gram stain, cultures and serology panel for bacteria, herpes simplex virus and cytomegalovirus were negative. In view of the findings the patient was treated with supportive care. Serological studies showed positive antiganglioside antibodies (anti-GQ1b, anti-GD1b and anti-GT1a), while determination of antibodies against myelin-associated glycoprotein, oligoclonal bands, autoantibody screening (antinuclear, small nuclear antiribonucleoproteins, antimitochondrial, antireticulin, anti-gastric parietal cell and anti-neutrophil cytoplasm) were negative. Tests for connective tissue disorders, antibodies against thyroid peroxidase and thyroglobulin, Lyme disease serology, mycoplasma IgM and syphilis tests were negative. In view of the findings a diagnosis of MFS was made. 48 hours after admission, the patient developed absence of deep tendon reflexes, respiratory failure, hypoxemia, and hypercapnia progressively associated with bulbar weakness, so she was intubated and transferred to the intensive care unit. Treatment was started with plasmapheresis (with total replacement of 5 volumes of plasma) and intravenous immunoglobulin (400 mg/kg/day). Significant clinical improvement was observed after the second exchange. After 5 sessions the patient was transferred to hospitalization and was discharged 18 days after admission. There was no evidence of alterations in fetal well-being during hospitalization. The patient was treated by the neurology service during follow-up. An outpatient control was performed one month after hospital discharge with the result of the electromyographic study, with improvement of muscle strength in lower limbs is 4/5 and upper limbs 5/5, both distal and proximal. Six months after the onset of symptoms, she still needs help to stand up. The patient was followed up weekly at the highrisk prenatal clinic without complications. At 38 weeks she presented spontaneous vaginal delivery without complications, obtaining a live female newborn of 3200 grams, with Apgar scores at 1minute and 5 minutes of 6 and 9 points, respectively. No neurological alterations were observed at the time of postnatal physical examination. DISCUSSION MFS is an acute autoimmune and demyelinating polyneuropathy characterized by acute onset of ophthalmoparesis, ataxia, and areflexia/hyporeflexia, but may also present with signs and symptoms indicative of generalized neuropathy(3). Demyelinating polyneuropathies can be triggered by an acute inflammatory response with evidence of inflammatory infiltrates and areas of segmental demyelination. In some cases, these have been associated with respiratory / gastrointestinal infections, acute cytomegalovirus infection, influenza vaccination, calcineurin inhibitor neurotoxicity and allograft rejection(6). The etiopathogenesis of MFS is associated with a phenomenon of molecular mimicry between gangliosides (important components of peripheral nerves) and some infectious agents(7). Gangliosides are ceramides bound to hexoses and N-acetylneuraminic acid, linked to an oligosaccharide core. Four gangliosides, GM1, GD1a, GT1a and GQ1b, differ in number and position of sialic acids(8). The most common hypothesis about the underlying mechanism is humoral immune response with deposition of activated complement and immunoglobulins with cellular response of macrophages and infiltrating T cells. Furthermore, the localization of these ganglioside antigens is associated with distinct clinical patterns(4). The diagnosis of MFS is based on symptomatology. Symptoms usually have acute onset within hours or days and clinical signs are diplopia (63%), sensory disturbance (52%), blepharoptosis (35%), facial palsy (35%), ataxia (33%), muscle weakness (25%) and dysesthesias (17%). Diplopia is a consequence of ophthalmoparesis, which is an early finding. Pupillary abnormalities are also common and may include pupillary asymmetry and slow reactivity to light(9). Moreover, ataxia is usually severe and makes independent ambulation difficult, despite preservation of muscle strength. Most patients with MFS have normal imaging findings, especially those with partial symptomatology(10). Cerebrospinal fluid analysis, although initially normal, may show cytologic-albumin dissociation. However, its results are only useful to exclude other pathologies with similar symptomatology(5). Nerve conduction studies and electromyography can help in the diagnosis, but have a limited role, since only in some cases abnormalities appear, which are more pronounced two weeks after the onset of symptoms(2). Differential diagnoses are with other infectious or autoimmune neurological pathologies, such as Bickerstaff's encephalitis, multiple sclerosis, Tolosa-Hunt syndrome, paraneoplastic syndromes (Eaton-Lambert syndrome), botulism, myasthenia gravis, poliomyelitis, and diphtheria(1,2). The main differential diagnosis during pregnancy is Wernicke's encephalitis, which is characterized by a clinical triad (nystagmus and ophthalmoplegia, mental status changes and ataxia) usually associated with thiamine deficiency. Magnetic resonance images show symmetrical T2 signal intensity alterations in medial thalamus, mammillary bodies, tectal plate and periaqueductal area(11). Approximately 80% to 90% of patients with MFS have antibodies against GQ1b. These play a key role in the pathogenesis of the syndrome, as ophthalmoparesis and ataxia are strongly associated with the presence of antibodies. In addition, there are reports of higher concentrations of the antibodies in the cerebrospinal fluid during the first 3 weeks of the disease(12). Treatment data from clinical trials of MFS are scarce, so management is based on the same guidelines used for GBS and should be initiated as early as possible to prevent irreversible nerve damage, mainly in patients with rapidly progressive weakness. Intravenous administration of high-dose immunoglobulin has been shown to be as effective as plasmapheresis in GBS and its variants, along with supportive care(13). Several reports indicate decreased nerve damage and more rapid clinical improvement after treatment. Good response to treatment has been reported in two-thirds of patients when initiated within two weeks of symptom onset, with full recovery of function within three to five months(12). Demyelinating polyneuropathies during pregnancy are rare and occur most frequently in the second and third trimester of pregnancy and in the first postpartum month, due to the predominance of Th1 cells that produce proinflammatory cytotoxic cytokines during this period. Prior to the advent of immunotherapies, obstetric patients experienced significant morbidity and mortality with 20% of patients on disability, 35% on ventilatory support and a mortality rate of 13%. The frequency of preterm delivery also increased in severe cases. Both the rapidity of disease onset and the severity and duration of paralysis are indicators of poor prognosis(14). To date, the impact of MFS during pregnancy and long-term perinatal outcomes is unknown. All patients with MFS should remain under hospital observation until it has been established that there is no evidence of clinical progression. Patient management should include prevention of deep vein thrombosis, identification and management of infections, pain management, bladder catheterization in case of urinary retention, laxatives in case of constipation, management of psychosocial stress resulting from the disease, and implementation of early, active and individualized rehabilitation programs. These measures can help to achieve a favorable outcome(15). In conclusion, MFS, a variant of GBS, is a rare condition during pregnancy. It is characterized by ophthalmoparesis, ataxia and areflexia/hyporeflexia and can be successfully treated with intravenous immunoglobulin or plasmapheresis. It is necessary to achieve accurate diagnosis and timely treatment and to be alert for unexpected autoimmune neurological disorders during pregnancy.

Uterine lipoleiomyoma

RESUMEN El lipoleiomioma es una neoplasia uterina benigna poco frecuente cuya incidencia varía entre 0,03% y 0,2%. Este tumor es considerado una variante benigna de los leiomiomas uterinos típicos. Está formado por una proporción variable de adipocitos maduros y células musculares lisas. La etiología puede estar relacionada con la deficiencia de estrógenos que se produce después de la transición menopáusica; generalmente aparece en mujeres obesas perimenopáusicas o menopáusicas. La sintomatología es inespecífica y la mayoría es diagnosticada de forma incidental. Se presenta un caso de lipoleiomioma uterino en paciente de 45 años quien consultó por presentar dolor abdominal. La ecografía mostró tumor en pared anterior de un útero homogéneo y bien definido. Durante la laparotomía se encontró tumor amarillento y de textura blanda. Se realizó histerectomía total más ooforosalpingectomía. El diagnóstico anatomopatológico fue de lipoleiomioma uterino.

ABSTRACT Lipoleiomyoma is a rare benign uterine neoplasm whose incidence varies between 0.03%-0.2%. This tumor is considered a benign variant of typical uterine leiomyomas. It consists of a variable proportion of mature adipocytes and smooth muscle cells. The etiology may be related to estrogen deficiency occurring after the menopausal transition; it usually appears in obese perimenopausal or menopausal women. The symptomatology is nonspecific, and most are diagnosed incidentally. We present a case of uterine lipoleiomyoma in a 45-year-old patient who consulted for abdominal pain. Ultrasonography showed a tumor in the anterior wall of a homogeneous and well-defined uterus. During laparotomy, a yellowish tumor with a soft texture was found. Total hysterectomy plus oophorosalpingectomy was performed. The anatomopathologic diagnosis was uterine lipoleiomyoma.

Vulvar fibroadenoma: case report

RESUMEN El fibroadenoma es una neoplasia benigna usualmente localizada en mama. Su localización vulvar es extremadamente rara, con publicación de pocos casos. Su origen es incierto y muy debatible, en tanto se piensa que puede originarse de un tejido mamario ectópico vulvar o de glándulas anogenitales similares a las de tejido mamario que existen normalmente. Se presenta un caso inusual de fibroadenoma vulvar en una mujer de 29 años que durante dos años evidenció tumoración a nivel de la vulva que le producía dispareunia y sangrado poscoital. A nivel del labio mayor de la vulva se extirpó un tumor bien delimitado de 3 x 2 x 2 cm, blanquecino, de consistencia firme. En la microscopia se observó un fibroadenoma que por inmunohistoquímica mostró positividad para receptores de estrógeno y progesterona.

ABSTRACT Fibroadenoma is a benign neoplasm usually located in the breast. Its vulvar location is extremely rare, with few cases published. Its origin is uncertain and highly debatable, as it is thought that it may originate from vulvar ectopic breast tissue or from anogenital glands similar to normally existing breast tissue. An unusual case of vulvar fibroadenoma is presented in a 29-year-old woman who for two years presented with a vulvar lump that caused dyspareunia and postcoital bleeding. At the level of the labium majus of the vulva, a well-demarcated tumor measuring 3 x 2 x 2 cm, whitish, with a firm consistency was excised. Microscopy showed a fibroadenoma which by immunohistochemistry showed positivity for estrogen and progesterone receptors.

Pure primary squamous cell carcinoma of the ovary

RESUMEN El carcinoma de células escamosas de ovario es una neoplasia maligna rara; su aparición es atribuible a la transformación maligna de un tumor ovárico existente. La variedad pura del carcinoma de células escamosas del ovario, en ausencia de lesiones ováricas preexistentes que incluyen quistes dermoides, tumores de Brenner o endometriosis, es extremadamente rara y se le considera una metaplasia del epitelio de superficie. Debido a su rareza, no se han establecido las características clínicas ni los tratamientos efectivos. La evaluación adecuada antes de la cirugía es fundamental para determinar el alcance de la cirugía y la terapia adyuvante. No existe acuerdo sobre la quimioterapia o radioterapia postoperatoria. El pronóstico de la enfermedad avanzada es generalmente pobre. Se presenta un caso de carcinoma de células escamosas primario puro de ovario.

ABSTRACT Ovarian squamous cell carcinoma is a rare malignant neoplasm; its occurrence is attributable to malignant transformation of an existing ovarian tumor. The pure variety of ovarian squamous cell carcinoma, in the absence of pre-existing ovarian lesions including dermoid cysts, Brenner’s tumors or endometriosis, is extremely rare and is considered a metaplasia of the surface epithelium. Because of its rarity, clinical features and effective treatments have not been established. Adequate evaluation prior to surgery is critical to determine the extent of surgery and adjuvant therapy. There is no agreement on postoperative chemotherapy or radiotherapy. The prognosis of advanced disease is generally poor. A case of pure primary squamous cell carcinoma of the ovary is presented.

Appendiceal goblet cell carcinoid tumor with endometrial metastasis

RESUMEN El tumor carcinoide de células caliciformes es una neoplasia mixta casi exclusiva del apéndice, con diferenciación neuroendocrina y mucinosa. La afección metastásica endometrial por carcinomas extragenitales, especialmente el tipo de células de anillo de sello, es rara. Se presenta un caso de tumor carcinoide de células caliciformes apendicular con metástasis endometrial. Se trató de paciente femenina de 70 años quien presentó sangrado genital. El examen ginecológico mostró sangrado genital en moderada cantidad de color rojo-marrón y cuello uterino endurecido. En la biopsia endometrial se halló nidos de células de anillo de sello. La impresión diagnóstica provisional fue carcinoma mal diferenciado de probable origen intestinal. Durante la intervención, el útero tenía consistencia pétrea, el apéndice cecal era fibrótico y engrosado y el epiplón engrosado con nódulos tumorales. Las secciones anatómicas del cuello y cuerpo uterino mostraron focos tumorales. En el apéndice cecal se encontró acúmulos de pequeño tamaño compuestos por células caliciformes. La inmunotinción fue positiva a sinaptofisina, CDX-2, EMA, CK20, CD56 focal. Estos hallazgos confirmaron el diagnóstico de tumor carcinoide de células caliciformes, un tumor caracterizado por infiltración de la pared apendicular por pequeños nidos o cordones de células caliciformes con mucina intracitoplasmática y expresión focal de marcadores neuroendocrinos. Estas neoplasias tienen un comportamiento más agresivo que los tumores neuroendocrinos. La metástasis endometrial es rara y puede ser confundida con un carcinoma primario de células de anillo de sello. Se debe considerar como diagnóstico diferencial después de excluir otros tumores primarios.

ABSTRACT Goblet cell carcinoid tumor is an almost exclusive mixed neoplasm of the appendix with neuroendocrine and mucinous differentiation. Endometrial metastatic involvement by extragenital carcinomas, especially the signet ring cell type, is rare. A case of appendiceal goblet cell carcinoid tumor with endometrial metastasis is presented. This was a 70-year-old female patient who presented with genital bleeding. The gynecological examination showed moderate red-brown genital bleeding and hardened cervix. Endometrial biopsy reported nests of signet ring cells. The provisional diagnostic impression was poorly differentiated carcinoma of probable intestinal origin. During surgery, the uterus had a stony consistency, the cecal appendix was fibrotic and thickened, and the omentum was thickened with tumor nodules. Anatomical sections of the cervix and uterine body showed tumor foci. In the cecal appendix, small clusters composed of goblet cells were found. Immunostaining was positive for synaptophysin, CDX-2, EMA, CK20, focal CD56. These findings confirmed the diagnosis of goblet cell carcinoid tumor, a tumor characterized by infiltration of the appendiceal wall by small nests or cords of goblet cells with intracytoplasmic mucin and focal expression of neuroendocrine markers. These neoplasms have a more aggressive behavior than neuroendocrine tumors. Endometrial metastasis is rare and can be mistaken for a primary signet ring cell carcinoma. It should be considered as a differential diagnosis after other primary tumors have been excluded.

Primary vulvar Merkel cell carcinoma

RESUMEN Las células de Merkel se describieron originalmente en el estrato basal de la epidermis, con propiedades neuroendocrinas. El carcinoma de células de Merkel de la vulva es una neoplasia extremadamente rara y altamente agresiva. Existen pocos casos de estos tumores, la mayoría de los cuales han sido considerados tumores neuroendocrinos. El origen histológico y la etiología de esta enfermedad son controvertidas. Debido a su rareza en esta localización, no está claro si se comporta de manera diferente a los carcinomas de piel similares en otras localizaciones. Se presenta un caso de carcinoma primario de células de Merkel vulvar. El examen de biopsia por escisión reveló una tumoración de 4 x 3 centímetros en el tercio posterior del labio mayor izquierdo de la vulva sin afectación de los ganglios linfáticos. La paciente fue sometida a vulvectomía radical y disección bilateral de ganglios linfáticos inguinales. La evaluación histológica postoperatoria no mostró metástasis regionales ni distantes.

ABSTRACT Merkel cells were originally described in the stratum basale of the epidermis with neuroendocrine properties. Merkel cell carcinoma of the vulva is an extremely rare and highly aggressive neoplasm. There are few cases of these tumors, most of which have been considered neuroendocrine tumors. The histologic origin and etiology of this disease are controversial. It is known for his aggressive behavior and propensity for early diffusion. Because of its rarity in this location, it is unclear whether it behaves differently from similar skin carcinomas in other locations. A case of primary vulvar Merkel cell carcinoma is presented. Excisional biopsy examination revealed a 4 x 3-centimeter tumor in the posterior third of the left labium majus of the vulva without lymph node involvement. The patient underwent radical vulvectomy and bilateral inguinal lymph node dissection. Postoperative histological evaluation showed no regional or distant metastases.