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      Ablación endometrial por histeroscopia: resultados, prevención y manejo de complicaciones

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          Abstract

          A mediados de la década de los 80, se introdujeron procedimientos que eliminan el espesor completo del endometrio como tratamiento del sangrado menstrual profuso. A pesar de que en el mundo, el número y la popularidad de estas técnicas, conocida como ablación endometrial, se ha incrementado ostensiblemente, en nuestro país continúa siendo una herramienta poco difundida y subutilizada. Este artículo aborda de manera crítica la racionalidad, indicaciones y complicaciones, de la ablación endometrial en el manejo del sangrado menstrual profuso, considerando su utilidad clínica frente a otras alternativas de tratamiento.

          Translated abstract

          In the mid 80's, procedures were introduced to eliminate the entire thickness of the endometrium as treatment of heavy menstrual bleeding. Although in the world, the number and popularity of these techniques, known as endometrial ablation has increased considerably, in our country remains a little known and underutilized tool. This article critically discusses the rationale, indications and complications of the endometrial ablation in the management of heavy menstrual bleeding, considering their clinical utility over other alternative treatments.

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          Most cited references107

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          An epidemiological survey of symptoms of menstrual loss in the community.

          For the early detection of gynaecological malignancy, guidance based on presenting symptoms exists to aid a general practitioner (GP) in determining who to investigate or refer. The evidence for this advice is based on the prevalence of symptoms in women with gynaecological malignancy or within specialist clinics. There are no studies on the incidence of symptoms within the community. To provide an estimate of the incidence of self-reported symptoms of menstrual loss in the community population of a single general practice. A prospective population-based cohort study of women identified through a baseline postal survey and followed 6 and 12 months later. An urban general practice with four partners and 10,000 registered patients. A postal baseline survey was undertaken on all women aged 18-54 years on the practice age-sex register. Responders who consented to follow-up were sent further questionnaires at 6 and 12 months. All questionnaires enquired about the presence or absence of symptoms related to vaginal bleeding. Twelve-month cumulative incidence rates were calculated using responders to the baseline, 6-month and 12-month questionnaires. A total of 2435 questionnaires were initially sent out at baseline and 1513 (62%) women replied to all three questionnaires. The 12-month cumulative incidence of symptoms in menstruating women was: menorrhagia 25% (95% confidence interval [CI] = 22 to 29); periods heavier than usual, 21% (95% CI = 18 to 23); change in pattern of cycle, 29% (95% CI = 26 to 32); short cycle 21% (95% CI = 19 to 24); long cycle 15% (95% CI = 13 to 18); intermenstrual bleeding 17% (95% CI = 14 to 19); postcoital bleeding 6% (95% CI = 5 to 8); prolonged period 9% (95% CI = 7 to 11). The development of symptoms of menstrual loss among women in the community is common, in contrast to the rarity of gynaecological malignancy. This raises concern about the usefulness of current guidelines, based on symptoms, advising women when to consult, and for the early detection of gynaecological malignancy in the community and primary care.
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            Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension.

            To examine the results of transcervical resection of submucous fibroids in relation to the degree of intramural extension. A prospective 3-year observational study was performed of transcervical resection of submucous fibroids for abnormal uterine bleeding. The mean follow-up was 20 months (range 10-34). Fifty-one patients with a mean age of 38 years (range 23-55) were treated with transcervical resection after classification according to the degree of intramural extension of the submucous fibroids. The intention was to perform complete resection, established at control hysteroscopy. A repeat procedure was performed in cases of incomplete resection unless the patient denied further hysteroscopic treatment. Outcome measures were control of bleeding, subsequent surgery, number of procedures, number of complete resections, and number of recurrences. Bleeding was controlled in 48 (94.1%) of all patients after final resection. Hysterectomy was performed in three patients (5.9%) because of persistent complaints: in two cases after incomplete resection and in one case after complete resection. Three patients were lost to follow-up. Of the remaining 45 patients (42 with complete and three with incomplete final resection), three (6.7%) had a recurrence (one after complete and two after incomplete final resection). With more extensive intramural involvement, the chance to achieve complete resection decreased and the mean number of procedures to achieve complete resection increased. Complete resection improves the long-term results of transcervical resection of submucous fibroids for control of abnormal uterine bleeding. Transcervical resection of submucous fibroids with more than 50% intramural extension should be performed only in selected cases, as complete resection usually necessitates repeat procedures.
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              Complications in hysteroscopy: prevention, treatment and legal risk.

              Fortunately, gynecologists are enthusiastically embracing diagnostic and operative hysteroscopy as a means to evaluate women with menstrual disorders, infertility, post-menopausal bleeding, recurrent pregnancy loss, and for ultrasound images. In general, operative hysteroscopy is a safe procedure, is easily learned, and has excellent surgical outcomes. As more obstetricians/gynecologists perform hysteroscopy, they must remain cognizant about the salient complications. The recognition of complications and prompt intervention will prevent adverse sequelae as well as minimizing undesirable patient outcomes and reducing legal risks. Hysteroscopy remains a relatively safe procedure. Diagnostic hysteroscopy has the fewest risks, followed by operative hysteroscopic adhesiolysis, metroplasty, and myomectomy. Fluid management is critical for intraoperative safety. Meticulous detail should be paid to fluid management, and consultation sought with a critical care specialist when fluid overload or hyponatremia is suspected. Lingering pain, fever, or pelvic discomfort after surgery requires prompt evaluation. Women becoming pregnant after operative hysteroscopic procedures need careful antepartum and intrapartum care. Special attention to unusual pain complaints during pregnancy or with fetal distress in labor need prompt intervention. The preoperative use of misoprostol or laminara decreases the risk of uterine perforation. Expert preoperative evaluation is essential in determining the surgical skill and expertise needed, surgical time, and the likelihood of completing the operative procedure. Overall, complications in operative hysteroscopy are infrequent and are usually easy to manage. This knowledge should help physicians perform more procedures.
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                Author and article information

                Journal
                rchog
                Revista chilena de obstetricia y ginecología
                Rev. chil. obstet. ginecol.
                Sociedad Chilena de Obstetricia y Ginecología (Santiago, , Chile )
                0048-766X
                0717-7526
                2011
                : 76
                : 6
                : 439-448
                Affiliations
                [02] orgnameUniversidad de Chile orgdiv1Facultad de Medicina orgdiv2Instituto de Investigación Materno Infantil Chile
                [01] orgnameUniversidad de Valparaíso orgdiv1Facultad de Medicina orgdiv2Departamento de Ginecología y Obstetricia Chile
                Article
                S0717-75262011000600012 S0717-7526(11)07600612
                10.4067/S0717-75262011000600012
                c3a15f06-412c-459d-9427-840ab9ee81eb

                This work is licensed under a Creative Commons Attribution 4.0 International License.

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                Figures: 0, Tables: 0, Equations: 0, References: 65, Pages: 10
                Product

                SciELO Chile

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                evidencia,first and second generation procedures,evidence,Ablación endometrial,Endometrial ablation,complicaciones,complications,procedimientos de primera y segunda generación

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