Revista Colombiana de Obstetricia y Ginecología

Evidence-based medicine and precision medicine: finding the balance between both

Economic analysis of the use of the Flt-1/PlGF preeclampsia ratio compared to the standard of care in Uruguay

RESUMEN Objetivos: La preeclampsia (PE) es un trastorno hipertensivo del embarazo que puede causar complicaciones graves y resultados adversos maternos y fetales. El objetivo del estudio fue estimar el impacto económico de la incorporación del cociente sFlt-1/PlGF (factor tirosinkinasa -1 soluble tipo fms / Placenta Growth Factor - Factor de Crecimiento Placentario) al sistema de salud uruguayo. Materiales y métodos: Se utilizó un árbol de decisión para estimar, en una cohorte hipotética de mujeres con sospecha de PE, el impacto económico anual incluidos los costos relevantes asociados con el diagnóstico, el seguimiento y el tratamiento de la presentación inicial de la PE clínicamente sospechada hasta el parto. Se analizaron los costos anuales para un escenario estándar de atención y un escenario que incluye el cociente sFlt-1/PlGF para PE. Se realizaron diversos análisis de sensibilidad determinísticos y probabilísticos. Resultado: El modelo económico estimó que el uso del cociente sFlt-1/PlGF permitiría al sistema de salud uruguayo ahorrar 95.432.678 pesos uruguayos (2.320.269 dólares) anualmente: una reducción del 5 % en comparación con el estándar de atención, principalmente como resultado de la reducción de las hospitalizaciones de mujeres con sospecha de PE. El cálculo del impacto económico estimó un ahorro neto anual de aproximadamente 10.602 pesos uruguayos (258 dólares) por paciente. Conclusiones: La introducción del cociente sFlt-1/PlGF en el sistema de salud uruguayo probablemente genere ahorros debido a la optimización del manejo de las hospitalizaciones de mujeres con sospecha de PE, aunque la posibilidad de obtener ahorros dependerá principalmente de la tasa actual de hospitalización de estas (la eficiencia del manejo de los embarazos de alto riesgo de PE), y de los días de internación de las mujeres hospitalizadas.

ABSTRACT Objectives: Preeclampsia (PE) is a pregnancy-related hypertensive disorder that can lead to severe complications and adverse maternal and fetal outcomes. This study aimed to estimate the economic impact of integrating the sFlt-1/PlGF ratio into Uruguay's healthcare system as part of routine clinical practice for diagnosing. Material and methods: A decision tree model was used to estimate the annual economic impact on the Uruguayan healthcare system for a hypothetical cohort of women with suspected PE. This included relevant costs associated with diagnosis, monitoring, and treatment from the initial presentation of suspected PE until childbirth. The study analyzed the annual costs under two scenarios: the standard-of-care and a scenario incorporating the sFlt-1/PlGF ratio for PE, using 2022 as the reference year. Various deterministic and probabilistic sensitivity analyses were performed. Results: The economic model estimated that the implementation of the sFlt-1/PlGF ratio could save the Uruguayan healthcare system $95,432,678 Uruguayan pesos (2,320,269 United States Dollars [USD]) annually, representing a 5 % reduction in costs compared with the standard of care. These savings were primarily due to a reduction in hospitalizations of women with suspected PE. The estimated economic impact equated to an annual net saving of approximately $10,602 Uruguayan pesos (258 USD) per patient. Conclusions: The introduction of the sFlt-1/PlGF ratio into the Uruguayan healthcare system is likely to generate savings due to the optimization of the management of hospitalizations for women with suspected preeclampsia (PE). However, the potential for savings will primarily depend on the current hospitalization rate of these women (the efficiency of managing high-risk PE pregnancies) and the length of stay for hospitalized women.

Prevalence, Characterization, and Risk Factors of Gestational Anemia in Quindío, Colombia, 2018-2023

RESUMEN Objetivos: Describir la prevalência y caracterizar la anemia gestacional en mujeres que asisten a control prenatal en el departamento del Quindío (Colombia), y describir los factores de riesgo asociados. Materiales y métodos: Estudio analítico de corte transversal. De 1.003 embarazadas se seleccionaron 307 mujeres. Se incluyeron gestantes ≥ 18 años, que asistieron al programa de control prenatal en tres instituciones privadas de alta complejidad, en Armenia (Quindío, Colombia), entre 2018 y 2023, para una ventana de observación de cinco años. Se excluyeron embarazadas con diagnóstico de malformaciones fetales y enfermedad hemolítica, las que se cambiaron de centro de atención o se mudaron del Quindío. Resultados: La edad media de las participantes fue de 28,14 ± 5,27 años. Se identificó una prevalencia de anemia gestacional del 26,38 %, siendo la hemoglobina promedio de 9,82 ± 1,74 g/dL. El 12,37 % presentó hemoglobina de 10,1-10,9 g/dL (anemia leve), 8,46 % de 7,1-10,0 g/dL (anemia moderada) y 5,53 % inferior a 7,0 g/dL (anemia severa). En el tercer trimestre la prevalencia de anemia aumentó al 41,97 % (n = 34/81), siendo anemia ferropénica en el 91,35 % (n = 74/81). El IMC < 18,5 (OR: 15,46; IC 95 %: 7,13-28,59), embarazo múltiple (OR: 9,73; IC 95 %: 1,49-26,83) y antecedente de anemia pregestacional (OR: 7,43; IC 95 %: 4,52-9,13), se asocian con anemia gestacional. Conclusiones: La prevalencia de anemia gestacional es mayor del 25 % y aumenta en el tercer trimestre. Es importante identificar los factores de riesgo durante la evaluación preconcepcional y en el control prenatal.

ABSTRACT Objectives: To describe the prevalence and characterize gestational anemia in women attending prenatal care in the department of Quindío, Colombia, and to identify associated risk factors. Material and methods: An analytical cross-sectional study was conducted. Out of 1,003 pregnant women, 307 were selected. The study included pregnant women aged 18 years or older who attended a prenatal care program at three high-complexity private institutions in Armenia (Quindío, Colombia) from 2018 to 2023, providing a five-year observation window. Pregnant women with a diagnosis of fetal malformations and hemolytic disease, those who changed healthcare centers, or moved out of Quindío were excluded. Results: The mean age of the participants was 28.14 ± 5.27 years. The prevalence of gestational anemia was identified as 26.38 %, with an average hemoglobin level of 9.82 ± 1.74 g/dL. Of these, 12.37 % had hemoglobin levels of 10.1-10.9 g/dL (mild anemia), 8.46 % had levels of 7.1-10.0 g/dL (moderate anemia), and 5.53 % had levels below 7.0 g/dL (severe anemia). In the third trimester, the prevalence of anemia increased to 41.97 % (n = 34/81), with 91.35 % (n = 74/81) of cases being iron-deficiency anemia. A BMI of < 18.5 (OR: 15.46; 95 % CI: 7.13-28.59), multiple pregnancy (OR: 9.73; 95 % CI: 1.49-26.83), and a history of pregestational anemia (OR: 7.43; 95 % CI: 4.52-9.13) were associated with gestational anemia. Conclusions: The prevalence of gestational anemia is over 25 % and increases in the third trimester. It is important to identify risk factors during preconception evaluation and prenatal care.

Colombian consensus for the diagnosis, prevention, and management of Rhesus disease

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ABSTRACT Objective: To train healthcare professionals involved in the care of Rh-D negative pregnant women, with the aim of standardizing the management of Rh isoimmunization prevention, timely antenatal diagnosis of Rh disease, fetal assessment, and treatment of fetuses with Rh disease, in order to prevent adverse perinatal outcomes. Materials and Methods: A group of 23 expert panelists participated in the development of the consensus through three rounds, answering a questionnaire consisting of 8 domains and 22 questions. A modified Delphi method was used until the consensus threshold among participants was reached, defined as 80% or greater agreement in responses. In the third round of the expert panel, a twenty-third question emerged, which was answered by one of the thematic leaders. The eight domains of antenatal management for Rh-D negative pregnant women were: 1) Rh-D determination, 2) initial prenatal care for Rh-D negative patients, 3) titration and periodicity of the indirect Coombs test, 4) sensitizing events, 5) administration of anti-D immunoglobulin (IgG), 6) Doppler velocimetry of the middle cerebral artery (MCA), 7) antenatal management of isoimmunized patients and anemic fetuses, and 8) timing for pregnancy termination based on different clinical scenarios. Based on these responses, and a review of international clinical practice guidelines, consensus statements were formulated, including recommendations, their justification, and adaptation to the local context. Results: The following recommendations were issued: 1. It is suggested that Rh-D negative women of childbearing age attend a preconception consultation. 2. It is recommended to determine maternal Rh-D status at the first contact with health services, either during the preconception consultation or at the first prenatal check-up. 3. For Rh-D negative patients, it is recommended to determine the Rh-D status of the child's father during prenatal care as early as possible, preferably before the 28th week of gestation. 4. For Rh-D negative primigravidas, where the father is Rh-D positive, it is suggested to: a) determine and quantify Rh-D antibodies (indirect Coombs test) during the first consultation and then quarterly, b) expand the obstetric history, with an emphasis on identifying sensitizing events, and c) provide parental counseling regarding potential risks, the need for additional tests, and the possibility of immunization during pregnancy. 5. During prenatal care for Rh-D negative multiparous patients with previous Rh-D positive offspring, the initial approach should include: a) determining and titrating Rh-D antibodies (indirect Coombs test); b) expanding the obstetric history, focusing on sensitizing events; and c) providing parental counseling about potential risks and additional tests. 6. After a sensitizing event, it is recommended to administer anti-D IgG within the first 72 hours at a dose of 1500 IU (300 μg). If not feasible, it can be administered up to 4 weeks after the event if it was not given initially. 7.1. For non-isoimmunized pregnant women (with a negative Coombs test and Rh-positive newborn), it is recommended to administer anti-D IgG between weeks 28 and 32, and within the first 72 hours postpartum if the newborn is Rh-positive. The dose is 300 μg IM or IV. 7.2. In the case of a cesarean section in an Rh-D negative patient with a Rh-D positive child, the consensus does not recommend doubling the dose of anti-D IgG. The dose remains the same as after a vaginal delivery: 300 μg IM or IV. 7.3. In a twin delivery involving an Rh-D negative patient with two or more Rh-D positive live-born infants, the consensus recommends not doubling the dose of anti-D IgG. The dose remains 300 μg IM or IV, the same as after a vaginal delivery. 7.4. For a non-isoimmunized Rh-D negative patient in the puerperium with immediate postpartum surgical tubal sterilization and an Rh-D positive neonate, anti-D IgG is recommended, assuming no prior sensitization, given the potential for reproductive decision changes or failure of the procedure. 8. An Rh-D negative patient is considered isoimmunized if: a) the indirect Coombs test is positive at any titer, provided anti-D IgG was not received in the previous month, or b) there is a history of adverse perinatal outcomes associated with Rh disease in prior pregnancies, such as hydrops. 9.1. If Rh-D negative women are isoimmunized, it is necessary to determine the anti-D antibody titer, as this titer correlates with the severity of the disease and determines the need for fetal anemia studies with Doppler velocimetry of the MCA. 9.2. For isoimmunized Rh-D negative patients, it is recommended to follow up with monthly quantitative indirect Coombs tests until week 24, then bi-weekly, or until reaching a critical titer (≥ 1:16). 10.1. Doppler ultrasound of the MCA is suggested for Rh-D negative patients with a positive indirect Coombs test and titers ≥ 1:16. 10.2. In non-isoimmunized Rh-D negative patients, the consensus does not recommend MCA Doppler velocimetry. 10.3. Weekly MCA Doppler ultrasounds are recommended for isoimmunized patients with indirect Coombs titers ≥ 1:16. 10.4. The consensus suggests adopting a cut-off value of ≥ 1.5 multiples of the median (MoM) of the peak systolic velocity for gestational age on MCA Doppler, as this value best correlates with fetal anemia. 11. The consensus suggests Cordocentesis when fetal anemia is suspected, and intrauterine fetal transfusion when cordocentesis shows severe fetal anemia. This procedure should be performed by trained personnel. 12. It is recommended to prolong pregnancy until the fetus has achieved sufficient lung and tissue maturation to improve perinatal survival, according to the indirect Coombs test titer threshold. Conclusions: It is essential to address Rh-D negative pregnant women, isoimmunized women, and fetuses with Rh disease in an appropriate and standardized manner, according to the Colombian context, across all levels of prenatal care. The recommendations issued in this consensus are expected to improve clinical care, as well as enhance perinatal health and neonatal quality of life in cases of Rh disease.

Subtotal vaginal hysterectomy with cervical ring preservation and cervical stump suspension to the sacrospinous ligament in women with pelvic organ prolapse: An exposed cohort study

RESUMEN Objetivos: hacer una aproximación a la seguridad y eficacia a corto plazo de la histerectomía vaginal con preservación de cuello uterino en pacientes con prolapso genital estadios II a IV. Materiales y métodos: estudio descriptivo tipo serie de casos. Se incluyeron mujeres con prolapso genital estadios II a IV, con indicación de histerectomía vía vaginal, con citología cérvico- vaginal negativa para malignidad, que fueron sometidas a histerectomía subtotal vía vaginal, con suspensión del muñón cervical al ligamento sacro-espinoso, del 1 de junio al 31 de diciembre de 2023 en una clínica general de alta complejidad. Se analizaron variables sociodemográficas y complicaciones a los seis meses del posoperatorio. Se presenta la técnica quirúrgica y se realiza análisis descriptivo y la exposición quirúrgica de la técnica con suspensión del muñón cervical al ligamento sacro-espinoso. Resultados: en el periodo descrito consultaron 10 pacientes, de las cuales ocho cumplieron los criterios de inclusión. La duración media del procedimiento quirúrgico fue de 133 min. El sangrado tuvo una media de 200 cc. Una paciente requirió uso de analgésico para el dolor neuropático periférico tipo pregabalina, con lo que se logró adecuado manejo del dolor posoperatorio. No se presentaron otras complicaciones intraoperatorias o posoperatorias. No hubo recurrencia de prolapso a los seis meses de evaluadas las pacientes. Conclusiones: la histerectomía subtotal vía vaginal con suspensión del muñón cervical al ligamento sacro-espinoso es una técnica de reparación quirúrgica que podría ser considerada para el manejo del prolapso uterino. Se requieren estudios aleatorizados que comparen esta técnica con otras alternativas de manejo para evaluar su eficacia a largo plazo y su seguridad.

ABSTRACT Objectives: To evaluate the short-term safety and efficacy of vaginal hysterectomy with cervical preservation in patients with genital prolapse stages II to IV. Materials and methods: This is a descriptive case series study. It included women with genital prolapse stages II to IV, indicated for vaginal hysterectomy, with negative cervicovaginal cytology for malignancy, who underwent subtotal vaginal hysterectomy with suspension of the cervical stump to the sacrospinous ligament between June 1 and December 31, 2023, at a high-complexity general clinic. Sociodemographic variables and complications six months postoperatively were analyzed. The surgical technique is presented, and descriptive analysis, along with a detailed surgical technique exposition of cervical stump suspension to the sacrospinous ligament, was conducted. Results: During the described period, 10 patients consulted, of whom eight met the inclusion criteria. The mean duration of the surgical procedure was 133 minutes. Average blood loss was 200 cc. One patient required analgesic use of pregabalin for peripheral neuropathic pain, achieving adequate postoperative pain control. No other intraoperative or postoperative complications were reported. No prolapse recurrence was observed six months postevaluation. Conclusions: Subtotal vaginal hysterectomy with cervical stump suspension to the sacrospinous ligament is a surgical repair technique that could be considered for the management of uterine prolapse. Randomized studies comparing this technique with other management alternatives are needed to evaluate its long-term efficacy and safety.

Precision surgical education

ABSTRACT Information and data are accelerating the implementation of competency-based medical education. The adoption of precision education can contribute to this purpose. This article discusses the extent to which precision surgical education can be used in assessing the minimum reliability standards of future surgeons - given the advent of Entrustable Professional Activities - and as an option to strengthen the career trajectory of residents.

RESUMEN La información y los datos están acelerando la implementación de la educación médica basada en las competencias. La adopción de la educación de precisión puede contribuir a este propósito. Este artículo analiza los alcances de la educación quirúrgica de precisión para la evaluación del desempeño de los futuros cirujanos en sus estándares mínimos de confiabilidad -ante el advenimiento de las actividades profesionales confiables -, y como alternativa para fortalecer la trayectoria profesional de los residentes.

MAGNESIUM SULFATE: 100 years saving maternal lives. A scientific heritage of humanity

RESUMEN El Sulfato de Magnesio completa 100 años en el manejo médico de la eclampsia. Lazard, a partir de mayo de 1924, en el Hospital General de los Ángeles, recogió las evidencias clínicas de sus beneficios sobre la mortalidad de la enfermedad convulsiva del embarazo. Se analizaron dosis, esquemas, diluciones, se encontró seguridad terapéutica para la madre y el feto, y finalizando el siglo XX, se realizaron experimentos clínicos aleatorizados que demostraron la utilidad clínica del magnesio para las siguientes indicaciones: tratamiento de la eclampsia, prevención de la eclampsia, protección neurológica del cerebro del prematuro menor de 32 semanas, entre otras. Todo este camino ha sido controvertido por muchas autoridades; sin embargo, la Universidad Nacional de Colombia y su Departamento de Obstetricia y Ginecología han defendido desde 1982 el esquema Zuspan como el ideal en el manejo de estas pacientes. Con esta revisión queremos mostrar todas las evidencias que han convertido al magnesio en un fármaco indispensable para disminuir la mortalidad materna en todo el mundo, especialmente en los países subdesarrollados.

ABSTRACT Magnesium sulfate marks 100 years in the medical management of eclampsia. Lazard, starting in May 1924 at the Los Angeles General Hospital, collected clinical evidence of its benefits on the mortality associated with pregnancy convulsions. Doses, regimens, and dilutions were analyzed, revealing therapeutic safety for both mother and fetus. By the end of the 20th century, randomized clinical trials demonstrated the clinical utility of magnesium for the following indications: treatment of eclampsia, prevention of eclampsia, and neurological protection of the brain in preterm infants less than 32 weeks of gestation, among others. This journey has been controversial among many authorities; however, the National University of Colombia and its Department of Obstetrics and Gynecology have defended the Zuspan regimen as the ideal approach for managing these patients since 1982. Through this review, we aim to present all the evidence that has established magnesium as an essential drug for reducing maternal mortality worldwide, especially in developing countries.

Carta al editor a propósito de “Interrupciones voluntarias del embarazo recurrentes. Estudio de prevalencia y exploración de factores asociados. Antioquia, Colombia, 2015-2021”