domingo, 31 de agosto de 2008

LIBRO DE HISTEROSCOPIA



AQUÍ LES TRAIGO UN LIBRO DE HISTEROSCOPIA PARA QUE SEA DE PROVECHO DE TODOS.















DESCARGA
PARTE I

PARTE II

sábado, 30 de agosto de 2008

EMBARAZO ECTOPICO


Una revisión sencilla pero con información básica.

jueves, 28 de agosto de 2008

EMBARAZO POSTERIOR A ESTERILIZACIÓN CON ESSURE

Pregnancy After Microinsert Sterilization With Tubal Occlusion Confirmed by Hysterosalpingogram
Author(s):

Ory, Erica M. MD1; Hines, Randall S. MD1; Cleland, William H. MD1; Rehberg, Jonathan F. MD1

Issue:
Volume 111(2, Part 2), February 2008, pp 508-510
Publication Type:
[Case Reports]
Publisher:
© 2008 The American College of Obstetricians and Gynecologists

BACKGROUND: Introduced to the U.S. market in late 2002 as a permanent method of contraception, a microinsert device is placed hysteroscopically into the fallopian tubes, not requiring incisions or general anesthesia. This report describes a case of pregnancy more than 6 months after a hysterosalpingogram (HSG) confirming bilateral occlusion after microinsert sterilization.

CASE: A 30-year-old gravida 1 para 1 woman desired permanent sterilization. The patient underwent microinsert device placement and 6 months later had an HSG that confirmed bilateral tubal occlusion. More than 6 months after the confirmatory HSG, the patient became pregnant and delivered a term infant by cesarean birth. Cornual perforation was noted at surgery.

CONCLUSION: This case illustrates pregnancy after microinsertion sterilization and an HSG confirming bilateral tubal occlusion, despite perforation. A microinsert device continues to be a viable option for sterilization.

A 30 year old gravida 1 para 1 morbidly obese woman presented to our clinic desiring permanent sterilization. The patient’s surgical history was significant for a cesarean delivery at term secondary to failure to progress. Her postoperative course was complicated by pulmonary edema and a wound infection requiring long-term wound vacuum placement. After being presented with several options for permanent sterilization, the patient decided to proceed with microinsert device placement.

The patient underwent the microinsert sterilization without complication. Findings at the time of hysteroscopy included a normal endometrial cavity and normal tubal ostia bilaterally. Expanded coils were trailing into the uterine cavity bilaterally after placement. Before discharge from the hospital, the patient received depomedroxyprogesterone acetate for contraception.

The patient was seen for her 6-week postoperative visit and was without complaints. A 3-month HSG was scheduled. The patient presented as scheduled for her HSG, which was performed using CooperSurgical (Trumbull, CT) surgical hysterosonography and hysterosalpingography catheter with a 1.5-mL balloon. Twenty milliliters of sonografin 38% organically bound iodine (diatrizoate meglumine and iodipamide meglumine) contrast media was used. The report was read as right tubal occlusion and left tubal patency with spillage of contrast into the peritoneal cavity. The patient was seen again in clinic, and the results were explained to her. Per the microinsert company’s guidelines, depomedroxyprogesterone was continued, and a repeat HSG was performed 3 months later. The interpretation was bilateral tubal occlusion (Fig. 1). A nonsteroidal anti-inflammatory drug was not given at the time of either HSG.

More than 6 months later, the patient missed her menstrual cycle and performed a pregnancy test at home, and the result was positive. The patient presented to the emergency department because of this, and a sonogram was performed. The patient was noted to have an intrauterine pregnancy at 7 weeks of gestation with fetal cardiac activity.

The patient had a routine prenatal course. The patient presented in active labor and, given her history of prior cesarean delivery, desired a repeat cesarean delivery, with a bilateral tubal ligation. At the time of surgery, the microinsert was found to have perforated the uterus in the left cornual area. A tubal ligation was then performed.




COMMENT

This case report is one of only two found reporting pregnancy after microinsert hysteroscopic sterilization and bilateral occlusion confirmed by HSG. We searched Ovid/Medline and PubMed using the following search terms in English: “microinsert device,” “permanent birth control,” “hysteroscopic sterilization,” and “conceptus.” Between January 2000 and July 2007, there is only one other case reporting pregnancy after microinsert device tubal sterilization with confirmed occlusion on HSG. This study by Moses et al 9 reports a patient who became pregnant despite an HSG showing tubal occlusion. This patient was ultimately found to have a microinsert perforating the uterine wall. There is another case report of failed tubal occlusion using the microinsert device permanent birth control hysteroscopic sterilization procedure; however, that report resulted in a patent tube by HSG, but pregnancy did not occur.6 In a reported case from Australia, the device was appropriately placed and retained; however, the device never occluded the right fallopian tube. In a follow-up editorial, the author questions the interpretation of the follow up HSG and plain film x-ray.7 The author states that the microinsert was lodged above the wall of the fallopian tube, most likely subserosal, and that two tracts can be seen on the x-ray.

Upon review of the early studies and phase II and III trials, complications were very limited. These included inability to place the device bilaterally due to anatomic, procedural, and device-related events, uterine wall or tubal perforations, some of which were thought to be due to a support catheter that has since been discontinued, and microinsert expulsion.2,3,4 In an early study, the device was placed bilaterally in 85% of women with no pregnancies reported, and the procedure was tolerated very well.4 In phase II trials, bilateral placement was successful in 88% of cases.3 There were no pregnancies reported in this trial. There was unsatisfactory placement in 4% of cases including one microinsert expulsion, six perforations, and two unsatisfactorily placed devices. At 3-month HSG, 96% showed bilateral occlusion, 3% had unilateral occlusion, and 1.5% had an “equivocal” HSG. At 6 months postprocedure HSG, all women who had at least one patent fallopian tube at the 3-month HSG showed bilateral occlusion.

During the phase III study, bilateral placement was achieved in 92% of cases.2 Of those with bilateral placement, HSG at 3 months showed bilateral occlusion in 92% of women. As in the phase II study, all women who did not have occlusion at 3 months had a 6-month postprocedure HSG, which showed bilateral occlusion. Complications included a 3% expulsion rate, a 0.9% perforation rate, and an unsatisfactory placement rate of 0.6%. Including all phases as of January 8, 2003, there were no pregnancies after 9,620 woman-months of exposure.2 In our case, the HSG was interpreted as showing bilateral tubal occlusion. The patient then became pregnant 6 months after the confirmatory HSG, nearly 1 year after her initial procedure. Some hypotheses as to how this could occur are suggested.

The first is that there was unsatisfactory placement with only two trailing coils into the uterine cavity. Ideally, there should be three to eight expanded coils. The microinsert device company recommends if there are fewer than 3 or more than 8 coils seen that the device should be left in place and the patient should be evaluated as planned by HSG at 3 months postprocedure. Our case followed this recommendation, and the device showed bilateral tubal occlusion at 6 months.

Another possibility is that at the time of HSG, tubal spasm occurred causing a false evaluation of tubal occlusion. An important consideration might be to give a nonsteroidal anti-inflammatory drug 30–60 minutes before the HSG, as is done at the time of the procedure. Another way to reduce tubal spasm is to slowly inject the contrast at the time of HSG. This, however, was not done during this case. Another theoretical explanation for pregnancy after microinsert device could be assisted reproductive techniques; this, however, was not the case in this patient. Last, as in the case by Moses et al 9 uterine perforation by the microinsert device in the proximity of the tubal ostia may mimic proper microinsert placement and bilateral tubal occlusion. As we later found out, this was the case in this patient.

This case illustrates pregnancy after microinsert device hysteroscopic sterilization and an HSG showing bilateral occlusion. As of the end of July 2007, the microinsert device website reports 130,000 procedures have been done. Our case and the case by Moses et al 9 are the only two that can be found, using our search criteria, that have had microinsert device with bilateral occlusion on HSG and a subsequent pregnancy. We now know that, as in the other case by Moses et al,9 there was a uterine perforation. In the context of knowing all sterilization procedures have a failure rate, a microinsert device continues to be a viable option for permanent sterilization. We continue to offer this procedure to our patients. We contend, however, that as with all medical procedures, failures do occur.



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