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Objective: This study aimed to investigate the effects of the presence of subchorionic hematoma (SH) in early pregnancies with threatened miscarriage (TM) on levels of first-trimester maternal serum markers, pregnancy-associated plasma protein-A (PAPP-A), and free ß-human chorionic gonadotropin (ß-hCG) levels. Methods: The data of TM cases with SH in the first trimester between 2015 and 2021 were evaluated retrospectively. The data of age and gestational age-matched TM cases without SH were also assessed to constitute a control group. Demographic characteristics, obstetric histories, ultrasonographic findings, and free ß-hCG and PAPP-A levels of the groups were compared. Results: There were 119 cases in the study group and 153 cases in the control group. The median vertical and longitudinal lengths of the SH were 31 mm and 16 mm. The median age of both groups was similar (p=0.422). The MoM value of PAPP-A was 0.088 (.93) in the study group and 0.9 (0.63) in the control group (p=0.519). Similarly, the MoM value of free ß-hCG was 1.04 (0.78) in the study group and 0.99 (0.86) in the control group (p=0.66). No significant relationship was found in the multivariate analysis between free ß-hCG MoM, PAPP-A MoM, age, gravida, and vertical and longitudinal lengths of the hematoma (p>0.05). Conclusion: The level of PAPP-A and free ß-hCG were not affected by the SH. Therefore, these markers can be used reliably in TM cases with SH for the first-trimester fetal aneuploidy screening test.
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Gonadotropina Coriônica Humana Subunidade beta , Hematoma , Primeiro Trimestre da Gravidez , Proteína Plasmática A Associada à Gravidez , Humanos , Feminino , Gravidez , Proteína Plasmática A Associada à Gravidez/análise , Primeiro Trimestre da Gravidez/sangue , Gonadotropina Coriônica Humana Subunidade beta/sangue , Hematoma/sangue , Hematoma/diagnóstico por imagem , Adulto , Estudos Retrospectivos , Biomarcadores/sangue , Estudos de Casos e Controles , Ameaça de Aborto/sangue , Córion/diagnóstico por imagemRESUMO
Background/Objective: Autoimmune thyroid diseases (AITD) affect 2 to 5% of the general population. This study aimed to determine changes in activity of A-Tg and A-TPO antibodies before, during, and after pregnancy in women with previous AITD. Methods: This was a single-center study with a retrospective review of the medical records of 30 female patients aged 25-41 years who came to our endocrinology service in the city of Santo André, state of São Paulo, Brazil, to investigate thyroid diseases. The following data were reviewed: total triiodothyronine (totalT3), total thyroxine (totalT4), free thyroxine (FT4), thyroid-stimulating hormone (TSH), and anti-TSH receptor antibodies (anti-TSH receptor or anti-thyrotropin receptor antibodies (TRAb), anti-thyroid peroxidase (A-TPO), and anti-thyroglobulin (A-Tg)). These data were reviewed for 30 patients before and during the three trimesters of pregnancy and during the three months after pregnancy. Results: During gestation, we observed a progressive decrease in the blood values of A-TPO and A-Tg, which reached their lowest values in the third trimester of pregnancy, but after birth, they returned to values statistically equivalent to those before pregnancy. Analyzing the three trimesters and the post-pregnancy period, A-TPO increased 192% between the first trimester and postpartum (p = 0.009); it increased 627% between the second trimester and postpartum (p < 0.001); and it increased >1000% between the third trimester and postpartum (p < 0.001). There was no significant difference in the A-TPO values between the pre- and post-gestational periods (p = 1.00), between the first and second trimesters (p = 0.080), or between the second and third trimesters (p = 0.247). Conclusions: According to the results presented here, we observed changes in the activities of A-Tg and A-TPO antibodies during and after pregnancy in women with previous AITD. In women who intend to become pregnant, are pregnant, or have given birth within three months, it is essential to monitor A-TPO, A-Tg, and thyroid function as well as serum thyroid hormones and TSH to identify thyroid dysfunction in a timely manner and adjust the treatment strategy to avoid the deleterious effects of hypothyroidism on both mother and baby during and after pregnancy.
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This study aimed to evaluate the effects of different doses of equine chorionic gonadotropin (eCG; 200 and 300 IU) administered at the end of a fixed-time artificial insemination (FTAI) treatment protocol on ovulation, pregnancy, and twin rates in Bos taurus beef heifers. In addition, pregnancy losses in heifers with singleton and twin pregnancies were determined. A total of 2382 Angus heifers treated with a 6-day estradiol/progesterone-based protocol for FTAI (J-Synch protocol) were randomly allocated to two experimental groups to receive 200 or 300 IU of eCG administered intramuscularly at the time of intravaginal progesterone device removal; FTAI was performed from 60 to 72 h after device removal. The pregnancy rate did not differ (P = 0.89) between the 200 and 300 IU eCG groups. The number of corpus luteum induced by both eCG doses was determined by ultrasonographic examination 14 days after insemination and those treated with 300 IU of eCG had a greater double ovulation rate (P < 0.05). In addition, 300 IU eCG treated heifers had a higher twinning rate on day 30 of gestation (P < 0.05) and parturition (P < 0.05). Pregnancy losses from 30 days of gestation to calving did not differ between heifers treated with 200 and 300 IU of eCG (P = 0.70). However, regardless of the experimental group, heifers bearing twins had greater pregnancy losses than heifers with singletons (P < 0.05). In conclusion, reducing the dose of eCG from 300 to 200 IU under FTAI treatment protocol decreases double ovulation and twinning rates, maintaining a similar pregnancy rate in heifers. Nulliparous cows carrying two fetuses suffer greater pregnancy losses than cows with singletons.
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Gonadotropinas Equinas , Inseminação Artificial , Ovulação , Animais , Feminino , Gravidez , Bovinos/fisiologia , Inseminação Artificial/veterinária , Ovulação/efeitos dos fármacos , Gonadotropinas Equinas/farmacologia , Gonadotropinas Equinas/administração & dosagem , Gonadotropina Coriônica/farmacologia , Gonadotropina Coriônica/administração & dosagem , Aborto Animal , Gravidez de Gêmeos , Progesterona/administração & dosagem , Progesterona/farmacologia , Taxa de GravidezRESUMO
This study evaluated the efficacy of the administration of different doses of equine chorionic gonadotropin (eCG; 0 IU, 200 IU, or 300 IU) at the time of the progesterone device removal in 2-year-old Nelore (Bos indicus) heifers synchronized for fixed-timed artificial insemination (FTAI). On day 0 (D0), a total of 398 heifers received 2 mg of oestradiol benzoate i.m., 0.53 mg of cloprostenol i.m., and an eight-day previously used (second use) intravaginal device containing 1 g of progesterone (P4). Eight days later (D8), simultaneous with the P4 device removal, 0.5 mg of oestradiol cypionate i.m. and 0.53 mg of cloprostenol i.m. were administered. At the same time, heifers were randomly assigned to receive one of the following treatments: G-0 IU (n = 141; no eCG treatment), G-200 IU (n = 132; treated with 200 IU of eCG), and G-300 IU (n = 125; treated with 300 IU of eCG). FTAI was performed 48 h after the P4 device removal (D10). Ultrasonographic evaluations were performed at D0, D10, and D17. Heifers were scanned to measure the size of the largest follicle (LF), the presence, number, and size of the corpus luteum (CL), and the ovulation rate. Subsequently, at D40, the heifers underwent scanning to determine the pregnancy rate and identify any twin pregnancies. Additionally, at D70, scans were performed to assess pregnancy loss (PG). Data were analysed by orthogonal contrasts [C1 (eCG effect): control x (200 IU + 300 IU) and C2 (eCG dose effect): 200 IU × 300 IU]. On D0, CL presence was similar between the groups [G-0 IU = 65.2% (92/141), G-200 IU = 55.3% (73/132), and G-300 IU = 63.2% (79/125); p = .16]. No interactions between the presence of CL on D0 and eCG treatment were found for any of the variables (p > .05). The diameter of the LF at FTAI (D10) was not influenced by eCG treatment (p = .22) or eCG dose (p = .18). However, treatment with eCG increased the diameter of the CL at D17 (G-0 IU = 15.7 ± 0.3 mmb , G-200 IU = 16.6 ± 0.2 mma , and G-300 IU = 16.6 ± 0.3 mma ; p = .001), regardless of the dose used (p = .94). The ovulation rate was higher in heifers treated with eCG [G-0 IU = 79.4%b (112/141), G-200 IU = 90.2%a (119/132), and G-300 IU = 93.6%a (117/125); p = .002], but there was no effect of eCG dose (p = .36). Pregnancy per AI (P/AI) on D40 [G-0 IU = 32.6%b (46/141), G-200 IU = 42.4%a (56/132), and G-300 IU = 42.4%a (53/125); P = 0.05] and D70 [G-0 IU = 29.1%b (41/141), G-200 IU = 40.9%a (54/132), and G-300 IU = 40.8%a (51/125); p = .02] were higher on heifers that received eCG; however, no dose effect was observed for P/AI on D40 (p = .89) nor D70 (p = .98). Pregnancy loss between D40 and D70 tended to reduce (p = .07) in eCG-treated heifers without dose effect (p = .91). Heifers with CL at D0 presented a greater follicle diameter (LF) on D10 (With CL = 11.2 ± 0.2 mm and Without CL = 10.2 ± 0.2 mm; p = .05), CL diameter on D17 (With CL = 15.8 ± 0.03 mm and Without CL = 11.8 ± 0.6 mm; p = .01), and ovulation rate [With CL = 95.5% (233/244) and Without CL = 74.7% (115/154); p = .01]. However, no difference in pregnancy rate at D40 (p = .52) and D70 (p = .84) was found. In conclusion, eCG treatment increases ovulation and pregnancy rates of heifers submitted to a FTAI protocol. Furthermore, eCG treatment increases the diameter of the CL after FTAI and reduces pregnancy losses. No dose effect was observed, suggesting Nelore (Bos indicus) heifers respond to 200 IU of eCG treatment for FTAI.
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Doenças dos Bovinos , Doenças dos Cavalos , Gravidez , Bovinos , Animais , Feminino , Cavalos , Progesterona/farmacologia , Aborto Animal , Ovulação , Estradiol/farmacologia , Cloprostenol/farmacologia , Inseminação Artificial/veterinária , Inseminação Artificial/métodos , Sincronização do Estro/métodosRESUMO
OBJECTIVE: To evaluate the efficacy of sublingually administered human chorionic gonadotropin (HCG) in combination with clomiphene citrate (CC) or letrozole (LTZ) for ovulation induction. METHODS: In this prospective, double-blind, randomized study, the patients were divided into two placebo groups and two intervention groups using CC, LTZ, and HCG. RESULTS: There were no statistically significant differences in ovulation induction between the groups. We compared endometrial thickness at the beginning of the cycle and during the pre-ovulatory period, and detected a moderately positive correlation when CC was administered with HCG. CONCLUSIONS: Sublingual HCG with CC caused a moderately positive correlation with endometrial thickening when compared with that at the beginning of the cycle and during the pre-ovulatory period. There was no significant change in the number of pre-ovulatory follicles.
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Infertilidade Feminina , Feminino , Humanos , Gonadotropina Coriônica/uso terapêutico , Clomifeno/uso terapêutico , Clomifeno/farmacologia , Fármacos para a Fertilidade Feminina/uso terapêutico , Infertilidade Feminina/etiologia , Letrozol , Nitrilas/farmacologia , Nitrilas/uso terapêutico , Indução da Ovulação/efeitos adversos , Estudos Prospectivos , Triazóis/farmacologia , Triazóis/uso terapêutico , Método Duplo-CegoRESUMO
La enfermedad trofoblástica gestacional es definida como un grupo heterogéneo de lesiones, las cuales surgen a partir del epitelio trofoblástico de la placenta luego de una fertilización anormal. Se presenta el caso de una paciente de 35 años de edad, con diagnóstico de neoplasia trofoblástica gestacional posmolar en etapa I, que se detectó tras estudios imagenológicos de seguimiento y determinación de la hormona gonadotropina coriónica humana, para lo cual llevó tratamiento con quimioterapia y terapéutica de mantenimiento con metotrexato por 5 días o metotrexato/ácido folínico por 8 días, hasta la normalización de la gonadotropina coriónica humana. Lo más relevante es que, aunque estos tumores abarcan menos del 1 % de los tumores ginecológicos, representan una amenaza para la vida de las mujeres en edad reproductiva.
Gestational trophoblastic disease is defined as a heterogeneous group of lesions, which arise from the trophoblastic epithelium of the placenta after abnormal fertilization. The case of a 35-year-old female patient is presented with a diagnosis of posmolar gestational trophoblastic neoplasia in stage I, which was detected after follow-up imaging studies and determination of human chorionic gonadotropin, for which she underwent chemotherapy treatment and maintenance therapy with methotrexate for 5 days or methotrexate/folinic acid for 8 days, until normalization of human chorionic gonadotropin The most relevant thing is that, although these tumors comprise less than 1% of gynecological tumors, they represent a threat to the life of women of reproductive age.
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Abstract Objective This study aimed to investigate the effects of the presence of subchorionic hematoma (SH) in early pregnancies with threatened miscarriage (TM) on levels of first-trimester maternal serum markers, pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotropin (β-hCG) levels. Methods The data of TM cases with SH in the first trimester between 2015 and 2021 were evaluated retrospectively. The data of age and gestational age-matched TM cases without SH were also assessed to constitute a control group. Demographic characteristics, obstetric histories, ultrasonographic findings, and free β-hCG and PAPP-A levels of the groups were compared. Results There were 119 cases in the study group and 153 cases in the control group. The median vertical and longitudinal lengths of the SH were 31 mm and 16 mm. The median age of both groups was similar (p=0.422). The MoM value of PAPP-A was 0.088 (.93) in the study group and 0.9 (0.63) in the control group (p=0.519). Similarly, the MoM value of free β-hCG was 1.04 (0.78) in the study group and 0.99 (0.86) in the control group (p=0.66). No significant relationship was found in the multivariate analysis between free β-hCG MoM, PAPP-A MoM, age, gravida, and vertical and longitudinal lengths of the hematoma (p>0.05). Conclusion The level of PAPP-A and free β-hCG were not affected by the SH. Therefore, these markers can be used reliably in TM cases with SH for the first-trimester fetal aneuploidy screening test.
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Assisted Reproductive technology encompasses all techniques involving ovarian stimulation to produce high-quality oocytes and manipulation of both oocytes and sperm in vitro to produce embryos for the purpose of reproduction. The final maturation of oocytes induced by a "trigger" is a crucial step with the potential to affect in vitro fertilization outcomes. Human chorionic gonadotropin has traditionally been used as a substitute for luteinizing hormone to induce final oocyte maturation and meiosis. However, this practice may cause a potentially fatal iatrogenic complication known as ovarian hyperstimulation syndrome, which can cause significant morbidity and, in rare cases, death in otherwise healthy women. Thus, gonadotropin releasing hormone agonists have been promoted as a safer alternative for inducing oocyte maturation, albeit at the expense of luteal phase defect. Since then, various combinations of gonadotropin releasing hormone agonists and human chorionic gonadotropin have been tried. This scoping review evaluates these trigger combinations in various types of responders.
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The hypothalamic-pituitary-gonadal axis plays a fundamental role in the endocrine regulation of the reproductive function in mammals. Any change in the function of the participating hormones or their receptors can lead to alterations in sexual differentiation, the onset of puberty, infertility, cancer development, and other dysfunctions. In this study, we analyzed the influence of persistently elevated levels of the human chorionic gonadotropin hormone (hCG), a powerful agonist of pituitary luteinizing hormone (LH), on the reproductive axis of female mice. As a consequence of chronic hCG hypersecretion through a global expression of the hCGbeta-subunit in transgenic (TG) female mice, a series of events perturbed the prepubertal to juvenile transition. The imbalance in gonadotropin action was first manifested by precocious puberty and alterations in gonadal hormone production, with the consequent ovarian function disruption and infertility in adulthood. The expansion of cumulus cells in vivo and in vitro, ovulatory capacity, and gene expression of ovulation-related marker genes after hormone stimulation were normal in 3-week-old TG females. However, the expression of genes related to steroidogenesis and luteinization such as Lhcgr, Prlr, and the steroidogenic enzymes Cyp11a1, Cyp17a1, and Cyp19a1 were significantly elevated in the TG females. This study demonstrates that the excessive secretion of hCG in concert with high prolactin, induced premature luteinization, and enhanced ovarian steroidogenesis, as was shown by the up-regulation of luteal cell markers and progesterone synthesis in the TG mice. Furthermore, progressively impaired reproductive function of the TG females occurred from the peripubertal stage to adulthood, thus culminating in infertility.
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Gonadotropina Coriônica , Infertilidade , Humanos , Camundongos , Feminino , Animais , Gonadotropina Coriônica/farmacologia , Gonadotropina Coriônica Humana Subunidade beta/genética , Gonadotropina Coriônica Humana Subunidade beta/metabolismo , Camundongos Transgênicos , Luteinização , Mamíferos/metabolismoRESUMO
OBJECTIVE: To describe the natural history of hydatidiform mole (HM) after intracytoplasmic sperm injection (ICSI), emphasizing the clinical and oncological outcomes, as compared to patients who had HM after spontaneous conception (SC). STUDY DESIGN: Retrospective historical cohort study of patients with HM followed at the Rio de Janeiro Federal University, from January 1st 2000-December 31st 2020. RESULTS: Comparing singleton HM after SC to those following ICSI there were differences in terms of maternal age (24 vs 34 years, p < 0.01), gestational age at diagnosis (10 vs 7 weeks, p < 0.01), preevacuation human chorionic gonadotropin levels (200,000 vs 99,000 IU/L, p < 0.01), occurrence of genital bleeding (60.5 vs 26.9%, p < 0.01) and hyperemesis (23 vs 3.9%, p = 0.02) at presentation, and time to remission (12 vs 5 weeks, p < 0.01), respectively. There were no differences observed in the cases of twin mole, regardless of the form of fertilization that gave rise to HM, except molar histology with greater occurrence of partial hydatidiform mole (10.7 vs 40.0%, p = 0.01) following ICSI. Univariate logistic regression for occurrence of postmolar GTN after ICSI identified no predictor variable for this outcome. However, after adjusting for maternal age and complete hydatidiform mole histology, multivariable logistic regression showed the risk of GTN with HM after ICSI had an adjusted odds ratio of 0.22 (95%CI:0.05-0.93, p = 0.04), suggesting a possible protective effect when compared to HM after SC. CONCLUSIONS: Singleton HM after ICSI are diagnosed earlier in gestation, present with fewer medical complications, and may be less likely to develop GTN when compared with HM after SC.
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Doença Trofoblástica Gestacional , Mola Hidatiforme , Neoplasias Uterinas , Masculino , Gravidez , Feminino , Humanos , Adulto , Lactente , Estudos Retrospectivos , Injeções de Esperma Intracitoplásmicas , Estudos de Coortes , Brasil , Sêmen , Mola Hidatiforme/patologia , Doença Trofoblástica Gestacional/patologia , Fertilização , Gonadotropina Coriônica , Neoplasias Uterinas/patologiaRESUMO
Equine chorionic gonadotropin (eCG) is a glycoprotein hormone widely used in timed artificial ovulation (TAI) and superovulation protocols to improve the reproductive performance in livestock. Until recently, the only eCG products available in the market for veterinary use consisted in partially purified preparations of pregnant mare serum gonadotropin (PMSG). Here, a bioactive recombinant eCG (reCG) produced in suspension CHO-K1 cells was purified employing different chromatographic methods (hydrophobic interaction chromatography and reverse-phase (RP)-HPLC) and compared with a RP-HPLC-purified PMSG. To gain insight into the structural and functional characteristics of reCG, a bioinformatics analysis was performed. An exhaustive characterization comprising the determination of the purity degree, aggregates and nicked forms through SDS-PAGE, RP-HPLC and SEC-HPLC was performed. Higher order structures were studied by fluorescence spectroscopy and SEC-HPLC. Isoforms profile were analyzed by isoelectric focusing. Glycosylation analysis was performed through pulsed amperometric detection and PNGase F treatment following SDS-PAGE and weak anion exchange-HPLC. Slight differences between the purified recombinant hormones were found. However, recombinant molecules and PMSG exhibited variations in the glycosylation pattern. In fact, differences in sialic acid content between two commercial preparations of PMSG were also obtained, which could lead to differences in their biological potency. These results show the importance of having a standardized production process, as occurs in a recombinant protein bioprocess. Besides, our results reflect the importance of the glycan moieties on eCG conformation and hence in its biological activity, preventing denaturing processes such as aggregation.
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Gonadotropina Coriônica , Gonadotropinas Equinas , Gravidez , Feminino , Animais , Cavalos , Glicosilação , Proteínas Recombinantes/química , Eletroforese em Gel de PoliacrilamidaRESUMO
INTRODUCTION: Gestational trophoblastic neoplasia (GTN) is a rare tumor that arises from trophoblastic tissues with high remission rates after chemotherapy treatment. GTN can develop from any gestational events, such as miscarriage, ectopic pregnancy, and preterm/term pregnancy, but is more frequent after hydatidiform mole. The sensitivity of this tumor to chemotherapy and the presence of an exceptional tumor marker allow high remission rates, especially when patients are treated in referral centers. AREAS COVERED: Observational, retrospective, prospective, systematic reviews, and meta-analysis studies focusing on GTN treatment. We searched PubMed, Medline, and the Library of Congress from January 1965 to May 2022. EXPERT OPINION: Early GTN diagnosis allows low-toxic and highly effective treatment. Even multimetastatic disease has high rates of remission with multiagent regimen chemotherapy. Surgery is reserved for uterine disease in patients who have completed childbearing, in cases of chemoresistance to multiagent regimens or in the rare cases of placental site trophoblastic tumor or epithelioid trophoblastic tumor. While resistance is managed by salvage chemotherapy, cases with limited clinical response to sequential regimens have been successfully treated with immunotherapy.
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Doença Trofoblástica Gestacional , Neoplasias Uterinas , Recém-Nascido , Gravidez , Humanos , Feminino , Estudos Retrospectivos , Estudos Prospectivos , Placenta/patologia , Doença Trofoblástica Gestacional/tratamento farmacológico , Doença Trofoblástica Gestacional/diagnóstico , Doença Trofoblástica Gestacional/patologia , Neoplasias Uterinas/tratamento farmacológicoRESUMO
Resumen ANTECEDENTES: La enfermedad trofoblástica gestacional es un padecimiento que incluye un grupo de tumores placentarios, consecuencia de una proliferación anormal del tejido del trofoblasto. Se caracteriza por una excesiva elevación de la gonadotrofina coriónica humana que se considera diagnóstica y un predictor pronóstico. CASO CLÍNICO: Paciente de 23 años con hiperémesis gravídica y aumento del tamaño del útero mayor para las siete semanas de gestación y cuantificación de las concentraciones de HGC anormalmente elevadas en comparación con su valor basal. Se descartaron los diagnósticos diferenciales de mola parcial hidatiforme, mola completa y embarazo múltiple. Se concluyó que se trataba de enfermedad trofoblástica gestacional. Se procedió a la evacuación de la cavidad uterina de la que se extrajeron abundantes porciones de tejido ovoconformacional y molariforme. El informe de Patología fue: útero arcuato con tumor de sitio placentario, endometritis crónica, cervicitis con metaplasia escamosa, quiste de Nabot y endometrio proliferativo tardío. CONCLUSIÓN: Puesto que las pacientes con enfermedad trofoblástica gestacional suelen tener un pronóstico sombrío se sugiere la histerectomía simple para llegar a la curación. Por la agresividad del tumor y resistencia a otros tratamientos es indispensable el monitoreo riguroso semanal de la cuantificación de la HCG.
Abstract BACKGROUND: Gestational trophoblastic disease is a condition that includes a group of placental tumors resulting from abnormal proliferation of trophoblast tissue. It is characterized by an excessive elevation of human chorionic gonadotropin which is considered diagnostic and a prognostic predictor. CLINICAL CASE: 23-year-old patient with hyperemesis gravidarum and uterine enlargement greater than 7 weeks' gestation and abnormally elevated HGC levels compared to baseline. The differential diagnoses of hydatidiform partial mole, complete mole and multiple pregnancy were ruled out. It was concluded that it was gestational trophoblastic disease. The uterine cavity was evacuated and abundant portions of ovoconformal and molariform tissue were extracted. The pathology report was: arcuate uterus with placental site tumor, chronic endometritis, cervicitis with squamous metaplasia, Nabot's cyst and late proliferative endometrium. CONCLUSION: Since patients with gestational trophoblastic disease usually have a dismal prognosis simple hysterectomy is suggested to reach cure. Because of the aggressiveness of the tumor and resistance to other treatments, rigorous weekly monitoring of HCG quantification is indispensable.
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Resumen ANTECEDENTES: El hipertiroidismo, en concurrencia con el embarazo, tiene una incidencia variable en los distintos trimestres de la gestación y puerperio. Predomina en el primer trimestre y a los 7 a 9 meses posparto. Se relaciona, principalmente, con enfermedad de Graves e hiperémesis gravídica por las concentraciones de gonadotropina coriónica humana. A partir del surgimiento de la infección por SARS-CoV-2 se documentó la asociación entre ambas enfermedades. CASO CLÍNICO: Paciente de 27 años, primigesta, con antecedente familiar materno de hipotiroidismo, con reporte de TSH pregestacional normal (2.3 mUI/mL). Al cabo de cuatro semanas de embarazo tuvo una infección no complicada por SARS-CoV-2, con prueba diagnóstica positiva de PCR. El diagnóstico y el tratamiento farmacológico fueron oportunos y se logró el estado eutiroideo que permitió suspender la medicación y mantener asintomática a la paciente desde el punto de vista endocrino. A las 36 semanas de embarazo se le diagnosticó preeclampsia severa, por lo que se decidió finalizar el embarazo mediante cesárea, con recién nacido masculino de 2550 g y 47 cm, sin complicaciones. En el seguimiento posparto la función tiroidea permaneció eutiroidea. CONCLUSIONES: En la paciente del caso fue aparente la relación entre la COVID-19 en el embarazo y el hipertiroidismo. El caso es de interés clínico porque permite analizar otros factores causales de la enfermedad tiroidea en el embarazo.
Abstract BACKGROUND: Hyperthyroidism associated with pregnancy has a variable incidence in different trimesters of pregnancy and puerperium. It predominates in the first trimester and at 7 to 9 months postpartum. It is mainly associated with Graves' disease and hyperemesis gravidarum due to human chorionic gonadotropin concentrations. Since the emergence of SARS-CoV-2 infection, the association between the two diseases has been documented. CLINICAL CASE: 27-year-old primigravida with a maternal family history of hypothyroidism and a reported normal pregestational TSH (2.3 mIU/mL). Four weeks into her pregnancy, she had an uncomplicated SARS-CoV-2 infection with a positive diagnostic PCR test. Diagnosis and pharmacologic treatment were timely, and euthyroid status was achieved, allowing discontinuation of the medication and keeping the patient asymptomatic from an endocrine standpoint. At 36 weeks' gestation, she was diagnosed with severe pre-eclampsia, and it was decided to terminate the pregnancy by cesarean section, with a male newborn weighing 2550 g and 47 cm without complications. At postpartum follow-up, thyroid function remained euthyroid. CONCLUSIONS: In the case patient, the association between COVID-19 in pregnancy and hyperthyroidism was evident. The case is of clinical interest because it allows the analysis of other causal factors of thyroid disease in pregnancy.
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Introduction: Hydatidiform mole is a type of gestational trophoblastic disease that results from the abnormal fertilization of an oocyte and causes nonspecific symptoms such as amenorrhea, metrorrhagia, and enlarged uterus. Although rare, its most characteristic symptoms include hyperemesis, early-onset pre-eclampsia, anemia, and respiratory distress. Case presentation: A 47-year-old Moroccan woman consulted the emergency department of the Hospital Clínico Universitario in Valladolid (Spain) after a month of persistent coughing and emesis. The patient reported epigastralgia and amenorrhoea for two months, as well as scant vaginal bleeding two days prior to consultation. Taking into account that the patient tested positive for pregnancy, that a heterogeneous intrauterine mass measuring 124x120mm was observed on transvaginal ultrasound, that no abnormal findings were reported on Doppler ultrasound, and that her serum ßhCG levels reached a value of 772.110 mIU/mL, a diagnosis of hydatidiform mole was suspected. Once informed about the possible therapeutic options, the patient decided to undergo a total hysterectomy, as she stated that she had already fulfilled her desire to be a mother. After the procedure, the patient's clinical condition improved, and the pathology report of the mass confirmed the diagnosis of partial hydatidiform mole. Conclusion: Early diagnosis of hydatidiform mole is paramount in order to provide adequate treatment and improve the prognosis of these patients. Therefore, despite its low incidence and non-specific clinical manifestations, it should be considered as a differential diagnosis for first-trimester metrorrhagia.
Introducción. La mola hidatiforme es un tipo de enfermedad trofoblástica gestacional que se presenta como resultado de la fertilización anormal de un ovocito y que ocasiona síntomas inespecíficos como amenorrea, metrorragia y aumento del tamaño del útero. Aunque infrecuentes, sus síntomas más característicos incluyen hiperémesis, preeclampsia de inicio temprano, anemia y distrés respiratorio. Presentación del caso. Mujer marroquí de 47 años que consultó al servicio de urgencias del Hospital Clínico Universitario de Valladolid debido a que había presentado tos y vómitos por un mes. La paciente refirió haber sufrido epigastralgia y amenorrea por dos meses, así como escaso sangrado vaginal en los últimos dos días. Teniendo en cuenta que la paciente dio positivo en una prueba de embarazo, que en la ecografía transvaginal se observó una masa intrauterina heterogénea de 124x120mm, que no se reportaron hallazgos anormales en la ecografía Doppler y que sus niveles séricos de ßhCG alcanzaron un valor de 772.110 mUI/mL, se sospechó un diagnóstico de mola hidatiforme. Una vez informada sobre las posibles alternativas terapéuticas, la paciente decidió someterse a una histerectomía total, pues refirió que ya había cumplido su deseo de ser madre. Luego de realizar procedimiento, la condición clínica de la paciente mejoró; además, el informe de patología de la masa permitió confirmar el diagnóstico de mola hidatiforme parcial. Conclusiones. El diagnóstico temprano de la mola hidatiforme es de gran importancia para ofrecer un tratamiento adecuado y, de esta forma, mejorar el pronóstico de estas pacientes. Por tanto, a pesar de su baja incidencia y sus manifestaciones clínicas inespecíficas, se debe considerar como diagnóstico diferencial de las metrorragias del primer trimestre.
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Interstitial pregnancy is a rare type of ectopic pregnancy that commonly results in uterine rupture and life-threatening haemorrhage. Interstitial ectopic pregnancies are associated with a 2-5% mortality rate and a high risk of uterine rupture before 12 weeks of gestation when compared to tubal pregnancy. Due to the thickness and distensibility of the interstitial segment of the Fallopian tube, ectopic pregnancy in this location attains a considerable size before complications arise. Unfortunately, this clinical entity may prove to be a diagnostic challenge, leading to delays in treatment and significant morbidity and mortality in women of reproductive age. Herein, we report a case of a ruptured interstitial ectopic pregnancy occurring at 17 weeks of gestation that was successfully managed with surgical intervention, after proving to be a diagnostic challenge.
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Resumen El embarazo ectópico roto es una emergencia quirúrgica cuyo diagnóstico, gracias a la interrelación de la cuantificación de la fracción beta de la hormona gonadotropina coriónica humana (HCG-β) y los hallazgos ultrasonográficos, se ha hecho más preciso. Sin embargo, el diagnóstico se vuelve difícil cuando clínicamente se encuentran datos sugestivos de embarazo ectópico con una HCG-β negativa. Presentamos el caso de una mujer de 25 años acude a valoración por referir 12,2 semanas de retraso menstrual, asociado a sangrado transvaginal y signos de irritación peritoneal, que cuenta con HCG-β negativa (< 5 mUI/ml). Se realizó un rastreo ultrasonográfico encontrando abundante líquido libre en cavidad, sin evidencia de embarazo intrauterino. Ante la alta sospecha de embarazo ectópico se realizó laparotomía exploradora, encontrando hallazgos sugestivos de embarazo ectópico roto, y se realizó salpingectomía. Finalmente, en el estudio posoperatorio se confirmó por histopatología un embarazo ectópico roto. Existen muy pocos reportes en la literatura internacional de pacientes con características clínicas de embarazo ectópico roto, con HCG-β negativa. Es importante la difusión de este tipo de casos con la finalidad de mejorar los abordajes diagnósticos y no restar importancia ante la sospecha clínica, a pesar de presentar una HCG-β negativa.
Abstract Broken ectopic pregnancy is a surgical emergency that due to the relation between the serum quantification of the of the beta subunit of human chorionic gonadotropin (β-HCG) and the ultrasonographic findings, there have been improvements to reach a precise diagnosis. However, there are very few reported cases in the literature where a broken ectopic pregnancy is described with negative serum results in β-HCG. We present a case report of a 25-year-old patient came to the evaluation for referring 12.2 weeks of menstrual delay, associated with transvaginal bleeding and data of peritoneal irritation, she had a negative β-HCG fraction (< 5 mIU/ml). A scan was performed ultrasound finding abundant free fluid in the cavity, without evidence of intrauterine pregnancy. Given the high suspicion of ectopic pregnancy, an exploratory laparotomy was performed, finding findings suggestive of a ruptured ectopic pregnancy, a salpingectomy was performed. Finally, in the postoperative study, a ruptured ectopic pregnancy was confirmed by histopathology. There are very few reported internationally were found a patient with clinical characteristics of broken ectopic pregnancy, with a β-HCG negative. It is important the scientific diffusion of this type of cases with the purpose of improving the diagnostic approaches and not underestimating importance to the clinical suspicion, despite presenting negative β-HCG results.
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Humanos , Feminino , Gravidez , Adulto , Gravidez Ectópica/diagnóstico , Gonadotropina Coriônica Humana Subunidade beta/análise , Gravidez Ectópica/cirurgia , Ruptura EspontâneaRESUMO
BACKGROUND: Primary central nervous system germinomas of the medulla oblongata are extremely rare and usually have been found in young female Asian patients. The authors present an illustrative case of a patient who presented with severe medullary and posterior cord syndrome, the first South American case published to date, to the authors' knowledge. OBSERVATIONS: Initially, the radiological differential diagnosis did not include this entity. The lesion was located at the obex and exhibited a well-delineated contrast enhancement without hydrocephalus. An emergency decompressive partial resection following functional limits was performed. After histological confirmation, radiotherapy was indicated, with complete remission achieved at a 6-month follow-up. The patient, however, continued to have a severe proprioceptive disorder. The literature review identified 21 other such patients. The mean age for this location was 23 years, with a strong female and Asian origin predilection. All tumors exhibited contrast enhancement, and only one presented with hydrocephalus. LESSONS: In the absence of elevated tumor markers, radiological clues such as a well-delineated, contrast-enhanced lesion arising from the obex, without hydrocephalus, associated with demographic features such as young age, female sex, and Asian heritage, should evoke a high level of suspicion for this diagnosis. Gross total resection must not be attempted, because this tumor is potentially curable with high-dose radiotherapy.
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BACKGROUND: Extragonadal choriocarcinoma is rare and can be associated with hyperthyroidism when producing very high levels of human chorionic gonadotropin. CASE PRESENTATION: A 62-year-old Hispanic female presented with a 3-week history of shortness of breath, palpitations, extreme weakness, new-onset hot flashes, and right flank pain. Her physical examination was remarkable for tachycardia, hepatomegaly, hyperreflexia, and tremor; goiter was absent. Laboratory studies revealed increased lactate dehydrogenase, alkaline phosphatase, suppressed thyroid stimulating hormone, very elevated T4, and absent thyroid stimulating immunoglobulin. 18F-fluorodeoxyglucose positron emission tomography-computed tomography exhibited hepatomegaly with multiple large fluorodeoxyglucose-avid liver masses and a focus of fluorodeoxyglucose avidity in the stomach with no structural correlate. A thyroid scan (99mTcO 4 - ) showed diffusely increased tracer uptake. She was started on propranolol and methimazole. Upon stabilization of severe thyrotoxicosis, upper endoscopy was performed, showing a ~ 5 cm bleeding lesion in the greater stomach curvature body; biopsy was consistent with choriocarcinoma; beta-human chorionic gonadotropin hormone was 2,408,171 mIU/mL. The patient received methotrexate followed by etoposide and cisplatin. Methimazole was titrated down, and upon liver failure the medication was stopped. The thyrotoxicosis was effectively controlled with antithyroid drug and concurrent chemotherapy. At ~ 1.5 months after initial diagnosis, the patient died due to bleeding/acute liver failure with coagulation defects followed by multiple organ failure. CONCLUSIONS: Severe thyrotoxicosis can represent an unusual initial presentation of metastatic choriocarcinoma in the setting of extreme elevation of beta-human chorionic gonadotropin. Primary gastric choriocarcinoma is an aggressive malignancy with very poor outcomes. The co-occurrence of severe thyrotoxicosis with advanced primary gastric choriocarcinoma and imminent liver failure complicates management options.
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Coriocarcinoma , Hipertireoidismo , Falência Hepática , Neoplasias Gástricas/patologia , Tireotoxicose , Coriocarcinoma/complicações , Coriocarcinoma/diagnóstico , Coriocarcinoma/tratamento farmacológico , Gonadotropina Coriônica/uso terapêutico , Gonadotropina Coriônica Humana Subunidade beta , Feminino , Hepatomegalia , Humanos , Hipertireoidismo/diagnóstico , Hipertireoidismo/tratamento farmacológico , Hipertireoidismo/etiologia , Falência Hepática/complicações , Masculino , Metimazol/uso terapêutico , Pessoa de Meia-Idade , Neoplasias Embrionárias de Células Germinativas , Gravidez , Neoplasias Testiculares , Tireotoxicose/complicações , Tireotoxicose/diagnóstico , Tireotoxicose/tratamento farmacológico , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: To identify possible clinical factors associated with hyperthyroidism at presentation and to assess post-evacuation thyroid function in women with complete hydatidiform mole (CHM). METHODS: This observational study included women with CHM attending a specialized Brazilian center in 2002-2018. Clinical and laboratory data (serum hCG, TSH, fT4) were collected at presentation. Factors associated with hyperthyroidism were assessed by logistic regression. Receiver-operating characteristic curves were built to determine the hCG cutoff for predicting hyperthyroidism at CHM presentation. Post-molar evacuation follow-up included clinical assessment and close thyroid function monitoring. RESULTS: Of 137 CHM patients, 69 (50.3%) had hyperthyroidism of any type (43.5% subclinical, 56.5% overt) at presentation. Uterine fundal height > 16 cm or > gestational age (GA), and theca lutein cysts >6 cm were significantly associated with both subclinical and overt hyperthyroidism. The optimal hCG cutoff for predicting hyperthyroidism was 430,559 IU/L (sensitivity 85.5%, specificity 83.8%). Post-evacuation hyperthyroidism/transient hypothyroidism conversion was observed in 13% of the women with hyperthyroidism at presentation. Among the patients not showing conversion to hypothyroidism, median time for TSH normalization was 2 and 3 weeks for subclinical and overt hyperthyroidism, respectively. In the women with overt hyperthyroidism, fT4 was normalized at 2 weeks. CONCLUSIONS: Uterine fundal height > 16 cm, uterine fundal height > GA, theca lutein cysts >6 cm, and hCG >400,000 IU/L at presentation are associated with greater risk of hyperthyroidism and its complications. Close monitoring thyroid function during postmolar follow-up showed that, as thyroid hormones are normalized within 2-3 weeks post-evacuation, the use of beta-blockers or antithyroid drugs can be rapidly discontinued.