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Background/Objectives: Cesarean delivery (CD) is a common procedure, but it can be associated with some increasing risks as the number of previous CD increases. Although women undergoing multiple CDs is very unusual in Spain, our center serves pregnant women with a history of three or more previous CDs with some frequency. We aimed to assess whether women who undergo multiple CDs (≥4) have more risks than those who undergo a third CD. Material and Methods: A retrospective cohort study was conducted with 161 pregnant women who had undergone ≥ 2 previous CDs and were monitored during their next pregnancy. The primary endpoint was to evaluate the obstetric hemorrhage rate in the multiple CD group and compare it with that in the third CD group. Secondary outcomes regarding maternal and neonatal complications were also analyzed. Results: Hemorrhage (7% and 10%; p = 0.522) and transfusion (3% and 8%; p = 0.141) rates were similar in both groups. The risk of dehiscence of the uterine segment (6% and 24%; p < 0.006), as well as hysterectomy (0 and 6.6%, p = 0.019), difficult abdominal opening (49% and 82%; p = 0.001), peritoneal adhesions (3% and 22%; p < 0.001), and difficult bladder separation (36% and 73%; p < 0.001), was higher in the multiple CD group. No uterine rupture or maternal-neonatal mortality was observed in either of the groups. Conclusions: Since undergoing multiple CD is uncommon, our study may be the largest sample in our environment. Our findings suggest that despite the potential risks of undergoing multiple CDs, maternal and neonatal outcomes are overall favorable.

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PURPOSE: To assess the frequency of severe pain perception during hysterosalpingo-contrast sonography (HyCoSy) in infertile women and to assess whether there are differences in the frequency of associated pain according to the contrast used. DESIGN: Systematic review and meta-analysis. PATIENTS: Women undergoing HyCoSy due to infertility. INTERVENTIONS: Searches were carried out in two databases (Pubmed and Web of Science). We included prospective or retrospective cohort observational studies that specified the type of contrast used during HyCoSy and reported data regarding the number of patients who perceived severe pain during the procedure and the scale used for pain perception score. MAIN OUTCOME MEASURES: Pooled frequency of severe pain perception during HyCoSy and the pooled frequency of severe pain perception based on the contrast used. RESULTS: Twenty-nine studies were included in this meta-analysis including a total of 7139 patients. In 10 studies, Saline solution with air was used as contrast EchoVist™ was used in ten studies, in five studies, SonoVue™ was used and in four studies, ExEm-Foam™ was used as contrast. Pooled estimated frequency of severe pain perception during HyCoSy was 6% (95% CI 4-9). No statistically significant differences have been described regarding frequency of severe pain perception in relation to the different contrasts used. CONCLUSIONS: HyCoSy is a tolerable outpatient procedure. We did not find any evidence that one specific contrast was better tolerated than any other was.

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Patients and clinicians alike want to know if stress causes infertility. Stress could impair with reproductive function by a variety of mechanisms, including compromise of ovarian function, spermatogenesis, fertilization, endometrial development, implantation, and placentation. Herein we focus on the pathogenesis and treatment of stress-induced anovulation, which is often termed functional hypothalamic amenorrhea (FHA), with the objective of summarizing the actual knowledge as a clinical guide. FHA is a reversible form of anovulation due to slowing of gonadotropin-releasing hormone pulse frequency that results in insufficient pituitary secretion of gonadotropins to support full folliculogenesis. Importantly, FHA heralds a constellation of neuroendocrine alterations with health concomitants. The activity of the hypothalamic-pituitary-adrenal axis is increased in women with FHA and this observation supports the notion that stress is the cause. The extent of reproductive suppression relates to individual endocrinological and physiological sensitivity to stressors, both metabolic and psychogenic, and chronicity.

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OBJETIVO: Recientemente varios trabajos han relacionado la disfunción tiroidea autoinmune con la diabetes gestacional (DG). El hipotético nexo de unión sería el desarrollo de la homeostasis proinflamatoria. Por ello nos propusimos estudiar si la presencia de anticuerpos antitiroideos se relaciona con la aparición de DG. MATERIAL Y MÉTODOS: Se estudiaron retrospectivamente 56 gestantes con valores de TSH ≥ 2,5 μU/ml en el primer trimestre. Se midieron anticuerpos antitiroideos y se realizó la prueba de O'Sullivan. Para el diagnóstico de DG se llevó a cabo una sobrecarga oral de glucosa (100 g) y se siguieron los criterios recomendados por el Grupo Español de Diabetes y Embarazo. RESULTADOS: Se constató anticuerpos antitiroideos elevados en 21 (37,50%) mujeres. Se diagnosticó DG en 15 (26,79%) pacientes, de las que 6 (10,71%) tenían anticuerpos positivos y 9 (16,07%) tenían anticuerpos negativos. Los datos fueron analizados mediante regresión logística exacta por LogXact-8 Cytel, no encontrándose diferencias significativas entre las pacientes diagnosticadas de DG con anticuerpos antitiroideos positivos y con autoinmunidad negativa (OR = 1,15 [IC 95% = 0,28-4,51]; p = 1,00). CONCLUSIONES: La presencia de autoinmunidad tiroidea en mujeres con TSH por encima de los valores recomendados al inicio de la gestación no se asocia con el desarrollo de DG. No obstante, la prevalencia de DG en estas pacientes es superior a la documentada en la población general española, lo que sugiere la necesidad de un seguimiento más estrecho en gestantes con TSH ≥ 2,5 μU/ml

OBJECTIVE: Some recent studies have related autoimmune thyroid dysfunction and gestational diabetes (GD). The common factor for both conditions could be the existence of pro-inflammatory homeostasis. The study objective was therefore to assess whether the presence of antithyroid antibodies is related to the occurrence of GD. MATERIAL AND METHODS: Fifty-six pregnant women with serum TSH levels ≥ 2.5 mU/mL during the first trimester were retrospectively studied. Antithyroid antibodies were measured, and an O'Sullivan test was performed. GD was diagnosed based on the criteria of the Spanish Group on Diabetes and Pregnancy. RESULTS: Positive antithyroid antibodies were found in 21 (37.50%) women. GD was diagnosed in 15 patients, 6 of whom (10.71%) had positive antibodies, while 9 (16.07%) had negative antibodies. Data were analyzed using exact logistic regression by LogXact-8 Cytel; no statistically significant differences were found between GD patients with positive and negative autoimmunity (OR = 1.15 [95% CI = 0.28-4.51]; P = 1.00). CONCLUSIONS: The presence of thyroid autoimmunity in women with TSH above the recommended values at the beginning of pregnancy is not associated to development of GD. However, GD prevalence was higher in these patients as compared to the Spanish general population, suggesting the need for closer monitoring in pregnant women with TSH levels ≥ 2.5 mU/mL

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OBJECTIVE: Some recent studies have related autoimmune thyroid dysfunction and gestational diabetes (GD). The common factor for both conditions could be the existence of pro-inflammatory homeostasis. The study objective was therefore to assess whether the presence of antithyroid antibodies is related to the occurrence of GD. MATERIAL AND METHODS: Fifty-six pregnant women with serum TSH levels ≥ 2.5 mU/mL during the first trimester were retrospectively studied. Antithyroid antibodies were measured, and an O'Sullivan test was performed. GD was diagnosed based on the criteria of the Spanish Group on Diabetes and Pregnancy. RESULTS: Positive antithyroid antibodies were found in 21 (37.50%) women. GD was diagnosed in 15 patients, 6 of whom (10.71%) had positive antibodies, while 9 (16.07%) had negative antibodies. Data were analyzed using exact logistic regression by LogXact-8 Cytel; no statistically significant differences were found between GD patients with positive and negative autoimmunity (OR = 1.15 [95%CI = 0.28-4.51]; P=1.00). CONCLUSIONS: The presence of thyroid autoimmunity in women with TSH above the recommended values at the beginning of pregnancy is not associated to development of GD. However, GD prevalence was higher in these patients as compared to the Spanish general population, suggesting the need for closer monitoring in pregnant women with TSH levels ≥ 2.5 mU/mL.

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OBJECTIVES: The purpose of this study was to assess whether a single determination of the serum cancer antigen 125 (CA-125) level provides additional information to sonography for specific diagnosis of benign adnexal masses in premenopausal women. METHODS: We conducted a retrospective study comprising 1058 premenopausal women (mean age, 34.8 years) with histologically proven benign adnexal masses. All women had undergone transvaginal sonography and serum CA-125 determination within 1 week before surgery and tumor removal. According to "pattern recognition" analysis, a presumptive diagnosis was provided on gray scale transvaginal sonography for all masses. Positive and negative likelihood ratios were calculated for gray scale sonography and gray scale sonography plus CA-125. RESULTS: Eighty-five women had bilateral masses (1143 masses analyzed). In 7 women with bilateral masses, the histologic diagnoses of the masses were discordant and were excluded. Histologic diagnoses were as follows: endometrioma, n = 452; dermoid cyst, n = 180; serous cyst, n = 158; hemorrhagic cyst, n = 119; mucinous cyst, n = 54; hydrosalpinx, n = 37; and other, n = 109. The median CA-125 level was significantly higher in endometrioma (71.9 IU/mL; range: 5-2620 IU/mL) and hydrosalpinx (59.2 IU/mL; range, 5-601 IU/mL) compared to all other tumor types (P < .001). The CA-125 level was 35 IU/mL or higher in 74% of endometriomas, 58% of hydrosalpinges, 34% of hemorrhagic cysts, 18% of mucinous cysts, 14% of dermoid cysts, and 8% of serous cysts. The positive and negative likelihood ratios for sonography and sonography plus CA-125 (335 IU/mL) for each kind of tumor were not statistically different except for endometrioma, for which the positive likelihood ratio for sonography plus CA-125 (55.0; 95% confidence interval, 27.5-109.9) was significantly higher than for sonography alone (19.2; 95% confidence interval, 13.6-27.1). CONCLUSIONS: Cancer antigen 125 screening does not add useful information for specific diagnosis of benign adnexal tumors, except for endometrioma. An elevated CA-125 level significantly increases the probability of such a lesion.

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OBJECTIVE: To investigate potential associations between dietary patterns (defined using factor analysis) and difficulty conceiving. DESIGN: Case-control study nested in a Spanish cohort of university graduates (Seguimiento Universidad de Navarra [SUN] Project). SETTING: Female university graduates all over Spain participating in the SUN Project. PATIENT(S): A total of 485 women, aged 20-45 years, reporting having presented with difficulty getting pregnant, and 1,669 age-matched controls who had at least one child. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reported difficulty getting pregnant. Data were collected from baseline and follow-up questionnaires of the SUN Project. RESULT(S): Two dietary patterns were identified. They were labeled as "Mediterranean-type" and "Western-type" patterns. A lower risk of difficulty getting pregnant was apparent in the highest quartile of adherence to the Mediterranean-type pattern compared with the lowest quartile (odds ratio 0.56, 95% confidence interval 0.35-0.95). Greater adherence to the Western-type dietary pattern showed no association with this outcome. CONCLUSION(S): A greater adherence to the Mediterranean-type dietary pattern may enhance fertility. Further evidence about the relationship between this dietary pattern and fertility is needed to develop nutritional interventions for women desiring to get pregnant.

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OBJECTIVE: To assess the effect of the mode of delivery (vaginal or cesarean section) on survival, morbidity, and long-term psychomotor development of extremely low birth weight (ELBW) infants. METHODS: A longitudinal observational study including 138 ELBW infants (73 born by c-section and 65 vaginally) was conducted. We analyzed the survival and short-term morbidity. We also studied the long-term neurocognitive and motor development using the McCarthy Scales of Children's Abilities (MSCA). RESULTS: Mortality was significantly higher in newborns delivered vaginally (49.3%) than those delivered by c-section (23.1%). Newborns delivered vaginally had a higher incidence of retinopathy and peri-intraventricular hemorrhage (P-IVH). Children who died had lower gestational age at birth and lower birth weight. After multivariate analysis only birth weight, gestational age at birth and P-IVH were independently associated to mortality. Regarding the long-term evaluation (MSCA), we observed that children born by c-section had lower incidence of abnormal results. CONCLUSIONS: The mode of delivery does not affect survival. Cesarean section provides lower morbidity and better prognosis for neurodevelopment long-term outcome in ELBW infants.

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In this study we aimed to assess the diagnostic accuracy of transvaginal ultrasound for assigning a specific diagnosis to benign adnexal masses in pre- and postmenopausal women. The study comprised 2146 adnexal masses in 1980 women. 1420 women were premenopausal and 560 were postmenopausal. Specific diagnosis of presumed histology of the lesion using gray-scale ultrasound findings was provided based on examiner's impression. Definitive diagnosis was obtained in all cases. Sensitivity and specificity for each diagnosis were calculated in both pre and postmenopausal women. Specificity for malignant tumors was significantly higher in premenopausal women (p<0.001). Sensitivity for endometrioma (p<0.05) and hemorrhagic cyst (p<0.01) was significantly higher in premenopausal women. There was a trend for a higher sensitivity for serous cyst in postmenopausal women (p=0.09). We conclude that the diagnostic performance of transvaginal gray-scale ultrasound for specific diagnosis of adnexal masses based on examiner's impression is different in premenopausal and postmenopausal women.

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Objetivo: Evaluar cuál es la situación actual de la bibliografía aportada en los proyectos de tesis doctoral en el Departamento de Obstetricia, Ginecología y Cirugía de la Universidad de Zaragoza entre los años 1995 y 2002, y dilucidar cómo influye ésta en la calidad de los proyectos de tesis, para poder hacer predicciones sobre la calidad de cualquier proyecto de tesis en función de sus parámetros bibliográficos. Material y método: Estudio analítico de casos y controles (proyectos con bibliografía y sin ella, respectivamente) en el que se analizan 273 proyectos de tesis corregidos por dos personas (546 sujetos evaluados) presentados en el Departamento de Obstetricia, Ginecología y Cirugía de la Universidad de Zaragoza entre los años 1995 y 2002. Resultados: Se halló asociación estadística entre la variable bibliografía (existente, incorrecta y no existente) y la calidad del proyecto de tesis (valoración corregida) comprobada mediante dos tests estadísticos. El número de citas bibliográficas parece estar algo relacionada linealmente con la valoración corregida (0,229). Mediante regresión lineal múltiple se proponen varios modelos, pero resultan de escaso poder predictivo. Conclusiones: 1. Para responder a la hipótesis conceptual de trabajo se podría decir que el apartado bibliográfico no influye en la calidad de los proyectos de tesis doctoral. 2. Sí que se observan relaciones ya comentadas, como que a grandes cantidades de citas el trabajo suele estar algo mejor calificado, de ahí que aunque nos salgan algunas variables significativas no nos expliquen prácticamente nada de la variabilidad de la respuesta. 3. La única variable que tiene valor predictivo o explicativo de la calidad del proyecto de tesis es el número de citas: a mayor número de citas, mayor calidad del proyecto de tesis, pero desgraciadamente es muy pobre, apenas un 8,5%

Objective: To evaluate the current situation of the publications cited in doctoral thesis proposals in the Department of Obstetrics, Gynecology and Surgery of the University of Zaragoza (Spain) between 1995 and 2002 and to determine the influence of the bibliography on the quality of thesis proposals with a view to predicting the quality of thesis proposals according to their bibliographic parameters. Material and method: We performed a case-control study (proposals with and without bibliography, respectively). A total of 273 thesis proposals corrected by two evaluators (546 subjects under study) and presented in the Department of Obstetrics, Gynecology and Surgery in the University of Zaragoza between 1995 and 2002 were analyzed. Results: A statistically significant association was found between the variable of bibliography (present, incorrect, or absent) and the quality of thesis proposals (corrected evaluation) verified by two statistical tests. The number of citations seemed to be linearly related to the corrected evaluation (0.229). Various models were proposed through multiple linear regression but these models had little predictive power. Conclusions 1. The publications cited did not influence the quality of doctoral thesis proposals. 2. Although some significant variables were found (a large number of cited publications was weakly correlated with higher quality), these variables explained practically none of the variability in quality. 3. The only variable with predictive or explanatory value on the quality of thesis proposals was the number of citations: the greater the number of citations the higher the quality but this variable explained only 8.5% of the variability in quality

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