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ERRNVPHGLFRVRUJ

Revisores
Andrs Anz Hernndez
Fabin Hilario Mendoza

Autora
Mar Muoz Muiz

Grupo
Editorial

CTO

NOTA

La medicina es una ciencia sometida a un cambio constante. A medida que la investigacin y la experiencia
clnica amplan nuestros conocimientos, son necesarios cambios en los tratamientos y la farmacoterapia.
Los editores de esta obra han contrastado sus resultados con fuentes consideradas de confianza,
en un esfuerzo por proporcionar informacin completa y general, de acuerdo con los criterios aceptados
en el momento de la publicacin. Sin embargo, debido a la posibilidad de que existan errores humanos
o se produzcan cambios en las ciencias mdicas, ni los editores ni cualquier otra fuente implicada
en la preparacin o la publicacin de esta obra garantizan que la informacin contenida en la misma sea
exacta y completa en todos los aspectos, ni son responsables de los errores u omisiones ni de los resultados
derivados del empleo de dicha informacin. Por ello, se recomienda a los lectores que contrasten dicha
informacin con otras fuentes. Por ejemplo, y en particular, se aconseja revisar el prospecto informativo
que acompaa a cada medicamento que deseen administrar, para asegurarse de que la informacin
contenida en este libro es correcta y de que no se han producido modificaciones en la dosis recomendada
o en las contraindicaciones para la administracin. Esta recomendacin resulta de particular importancia
en relacin con frmacos nuevos o de uso poco frecuente. Los lectores tambin deben consultar
a su propio laboratorio para conocer los valores normales.

No est permitida la reproduccin total o parcial de este libro, su tratamiento informtico, la transmisin
de ningn otro formato o por cualquier medio, ya sea electrnico, mecnico, por fotocopia, por registro
y otros medios, sin el permiso previo de los titulares del copyright.
CTO EDITORIAL, S.L 2016
Diseo y maquetacin: CTO Editorial
a Francisco Silvela, 106; 28002 Madrid
Tfno.: (0034) 91 782 43 30 - Fax: (0034) 91 782 43 43
E-mail: ctoeditorial@ctomedicina.com
Pgina Web: www.grupocto.es
ISBN Ginecologa y obstetricia: 978-84-16527-25-0
ISBN Obra completa: 978-84-16527-11-3
Depsito legal: M-26880-2015

a y nhstfitrinia

ERRNVPHGLFRVRUJ
Manual CTO

de Medicina y Ciruga
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Grupo CTO
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ERRNVPHGLFRVRUJ

Ginecologa y obstetricia

Recommended reading 1

In the face of a cardiotochographic recordlng where we find what is


shown in the attached image, indcate which of the following answers
would be the most likely to justify it [Figure 1 a ] :
1.

Hypoxaemia and acidosis.

2.

Failure of the placenta to adequately perform gas exchange.

3.

Foetal head compression.

4.

Decreased oxygen supply to the foetus.

5.

Uterine hypertonia.

Since this is a direct question, the wording does not add any data to guide us. We are completely dependent on our capacity to interpret the image. However, we can start from the possible answers in order to find the
solution.
Answers nos. 1, 2 and 4 describe situations that would produce foetal
hypoxia. Therefore, in the three situations, the expected alteration would
be type II DIPs. Even if you are not capable of recognising them, you can
imagine that we are not observng this type of deceierations, since they
could be produced by at least these three answers, and, evidentiy, aii
three cannot be simultaneously correct. Consequently, what we see in
this image cannot be type 11 DiPs. As regards answer no. 5, uterine hy-

Figure 1a.

pertonia could hinder gas exchange, due to the compression that the
myometrium would produce on the vesseis, since t is hypertonic. There-

pression, and are due to vagus nerve stimulation, for which reason they

fore, this answer has something in common with nos. 1,2 and 4, and, as a

subside with atropine.Type II DIPs do show such a time gap, greater than

result, we shouid not trust it. However, option no. 3 stays"hanging". Even

20 seconds between the decrease in heart rate and the uterine contrac-

without great knowiedge about the subject, it could be identified as the

tion.They are caused by foetal acidosis and, therefore, have a worse prog-

correct answer by eiimination.

nosis than type I DIPs. In fact, the appearance of type II DIPs is an indication to study the foetal pH by means of microtomy.

What the image shows are type I DIPs. As you can see, the decreases in
heart rate are completely synchronous with the uterine contractions,

Below, you can compare type I DIPs and type II DIPs; it is easy to distin-

without any time gap.They are usually associated with foetal head com-

guish them in the case of a typical image.

143

ERRNVPHGLFRVRUJ

I
logiay
Recommended reading 1

FHR bpm

FHR bpm

-200-

-2() 0 -

-1f 3 0 -

-1{50-

-160-

1
Ai

- 1 0 0 - Ti
80 -

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Ha

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b
b 4

100

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/
/

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41

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1 .

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60 -\

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4r
t

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- 60 -

/v

t 4

A-

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oU

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60
I1

1
AtS
1
z
1

Figure I b . DIP

Figrele. DIP II.

Good prognosis

Bad prognosis

Intermedate prognosis

Foetal heart rate

120to 160

> 160

< 120

Variability

10to25

5to 10

< 5 or sinusoidal

ncreases

Present

Absent

Absent

Deceierations

DIP!

Umbilical DIPs

DIP II

Pos's test

< 20% DIP II in 10 contractions

20% to 30% DiP Ilin 10 contractions

> 30% DIP II in 10 contractions

Foetal blood pH

7.25 to 7.45

7.20 to 7.25

< 7.20

O saturation by pulse oxymetry

> 30%

10%-30%

<10%

Figure I d . Evaluation of the foetus'well-being.


Fuente: Garca Macarrn J. Casos clnicos en imgenes. Madrid. CTO Editorial, 2012.

ERRNVPHGLFRVRUJ

Ginecologa y obstetricia

Recommended reading 2

26-year-old patient, smoker, childiess, without a stable partner, is referred to your office due to a pap smear that is positive for HSIL (highgrade intraepithelial lesin). You perform a colposcopy and obtain the
image shown below. In the face of such finding, indcate the most suitable action [Figure 2a]:
1.

HPV (human papilloma virus) vaccine.

2.

Treatment with local anti-inflammatory agents.

3.

Extended study of the disease.

4.

Biopsy of the lesin.

5.

Cervical conisation.

This is a relatively easy question, since it can be easily answered by means


of the algorithm shown below.
When finding an abnormal pap smear, the next procedure to be performed would be a colposcopy, which, according to the question, has already been performed.

Figure 2a.

The image presented to us is known as acetowhite epithelium, i.e. the

ges in colour and leukcoplakia, presence of vascular neoformations and

lesions acquire a whitish colour using acetic acid.This s considered to be

irregular surface with loss of normal epithelium.

an abnormal colposcopic finding; for this reason, we shouid biopsy the


lesin (answer no. 4 correct). Remember that abnormal colposcopic fin-

Fuente: Garca Macarrn J. Casos clnicos en imgenes. Madrid. CTO Edi-

dings include acetowhite epithelium, iodine-negative epithelium, chan-

torial, 2012.
Healing

Abnormal pap smear

Observation

Colposcopy

Negativa

Repeat
pap smear

Unsatisfactory
(transition rea
is not visualised)

Cryotherapy,
lser or
thermocoagulation

Positiva
Cervical
intraepithelial
neoplasia

Endocervical
curettage

Highgrade
SIL

Conisation

Biopsy ^
1^ Positive

Negativa

and staging

\
Diagnostic
conisation

Negativa

Follow-up

Figure 2b. Diagnosis and treatment of cervical dysplasias

ERRNVPHGLFRVRUJ

Ginecologa y obstetricia.

Recommended reading 3

Patient who presents 7-week's amenorrhoea, asymptomatic, has a beta-hCG level of 2,500 mU/ml and the ultrasound shown below. In the
face of these data, you shouid first conslder [Figure 3a]:
1.

Gestation with a normal evolution corresponding to the amenorrhoea.

2.

Normal gestation with a shorter evolution than the amenorrhoea.

3.

Ectopic gestation with an asymptomatic evolution.

4.

Complete early miscarriage with total expulsin of intrauterino


ovule remainders.

5.

Initial molar pregnancy, without intrauterine ultrasound signs.

What the ultrasound image that accompanies this question shows is an


empty uterus. Bearing in mind the other two facts (amenorrhoea and increase in beta-hCG levis), we will analyse each of the options.

Figure 3a.

The first option to be considered is the presence of a pregnancy.


However, the fact that the uterus is empty on the seventh week

Early miscarriage causes a haemorrhage in the first trimester, accom-

shoud make us suspect that the evolution is not"normal", which dis-

panied by a suppression of beta-hCG levis; therefore, this may aiso

cards the first two answers. Do not forget that vaginal ultrasound is a

be discarded.

very sensitiva, precocious method for the diagnosis of gestation, to


the point that it can detect the gestational vesicle on the fifth week,

Therefore, the answer that best fits this clinical case is ectopic gestation

and the embryo on the seventh week.

with an asymptomatic evolution (answer no. 3 correct). It expiains the

The presence of a uterus without any sign of occupation con-

amenorrhoea and is compatible with the beta-hCG levis.These are high,

tradicts the diagnosis of molar pregnancy, which invalidares

but not as high as in the case o a normal pregnancy, which is typical of

answer no. 5. The hydatidiform mole evolves with the typical

ectopic pregnancies.

"snowstorm" image. Moreover, the beta-hCG levis would be


disproportionately high (2,500 mU/ml is a iow level for the ges-

Fuente: Garca Macarrn J. Casos clnicos en imgenes. Madrid. CTO Edi-

tational age).

torial, 2012.

146

ERRNVPHGLFRVRUJ

Ginecologa y obstetricia

Recommended reading 4

A 56-year-old patient visits the gynaecologist's office for a check-up.


Her history includes the presence of cycllc mastodynia with increased
breast density, currently asymptomatic. The examination does not
show tumours in the breasts or axillary adenopathles. A mammography of the right breast is performed, and the Image is shown below.
What would be the most appropriate therapeutic action? [Figure 4a]:
1.

The mammography is normal. We will continu with the normal


screening, with the next check-up at two years.

2.

Percutaneous appllcatlon of a progesterone gel if the mastodynia

reappears.
3.

Supplement the study with an ultrasound and, f It Is normal,

z0

schedule a check-up In one year.


4.

Puncture of the lesin in the office, with a cytological study of the


result.

5.

Deferred biopsy, following marking with a harpoon.


Figure 4a.

Even though we do not find any nodules when palpating the patient,
the mammography reveis an increase in density with fuzzy edges, and a
focal locatlon.This finding must lead us to suspect malignancy; therefore,
it is imperative to take a sample for histological study.
Bearing this in mind, the reasonable doubt would be between options 4
and 5. Answer no.4 cannot be correct: an FNAP cannot be performed, because there is no identifiable rea to the touch. Note that the question insists on the fact that there are no palpable nodules.Therefore, performing
the puncture would be like stabbing blindiy. Therefore, we will need to
markthe rea with a harpoon, in order to obtain the biopsy of the regin
of interest (answer no. 5 correct).
Mammography is the method whereon breast cncer screening is currently based. Below, we describe the mammographic signs that are considered to show potential malignancy:
1.

The suspicious sign of malignancy that appears earliest in mammography are microcalcifications. These would be anarchically clustered, in a number of five or more, not disseminated, linear or branched, with a segmental distribution and a symmetrical size.

2.

Presence of a dense, spiculated nodule, with fuzzy edges, and cutaneous retraction oroedema.The oedema would be caused by the
obstruction of the sub-dermal lymph nodes by the tumoural cells.

Figure 4b. Clustered microcalcifications.

Clinically, the typical manifestation is the peau d'orange.


3.

Loss of the normal architecture of the mammary tissue.

Fuente: Garca Macarrn J . Cosos clnicos en imgenes. Madrid. CTO Ed'

4.

Focal asymmetric densities.

torial, 2012.

147

ERRNVPHGLFRVRUJ

V l l Co S

Vdeo 1. Visualizacin de la cavidad endometrial por histeroscopia

Ginecologa y oi]5^^^^^

Vdeo 3. Laparoscopia diagnstico-teraputica en endometriosis

Vdeo 4. Miomectoma Iaparoscpica en la que se observa un mioma


intramural
Vdeo 2. Bloqueo tubrico mediante dispositivo intratubrico

148

ERRNVPHGLFRVRUJ

G i n e c o l o g a y obstetricia

Vdeo 6. Videoecocardiografa fetal en la semana 20

49

ERRNVPHGLFRVRUJ

Manual CTO de Medicina y Ciruga, 2.^ edicin

Bibliografa
Ginecologa y obstetricia
g

Berek JS, Hacker NF. Ginecologa oncolgica prctica. 4A ed. MeGraw HUI. Mxico, 2006.

Gonzlez-Merlo J . Obstetricia. 5.^ ed. Editorial Masson. Barcelona,


2006.

Cabero L, Saldvar D, Cabrillo E. Obstetricia y Medicina MaternoFetai. Editorial Mdica Panamericana. Buenos Aires, 2007.

Usandizaga JA, De la Fuente P. Tratado de Obstetricia y Ginecologa. 2.3 ed. McGraw-Hill Interamericana. Madrid, 2007.

Grupo CTO. Manual CTO de Ginecologa y obstetricia. 9.^ ed., CTO g


Editorial, Madrid, 2014.

Vanrell J . Endocrinologa ginecolgica y anticoncepcin. 2.^ ed. Editorial Masson. Barcelona, 1999.

Gonzlez-Merlo J , Gonzlez Bosquet J , Gonzlez Bosquet E. Ginecologa. 8.^ ed. Masson. Barcelona, 2006.

ERRNVPHGLFRVRUJ