Acta Obstétrica e Ginecológica Portuguesa

New Biomarkers in Obstetrics

Fractional CO2 laser treatment for vulvovaginal atrophy

Overview: Fractional CO2 laser treatment for vulvovaginal atrophy (VVA) is a ground-breaking treatment according to recent studies. Although local estrogens are considered the first line treatment for severe VVA in postmenopausal women, a significant proportion of patients do not respond, do not adhere or have contraindications to hormonal treatments. In these situations, fractional CO2 laser may represent a good alternative. Aims: To analyze the efficacy and safety of fractional CO2 laser treatment for VVA. Study design: Retrospective observational study Population: 27 postmenopausal women treated for VVA with 2 or 3 sessions of fractional microablative CO2 laser system. Methods: We inquired patients about VVA symptoms (vaginal dryness, dyspareunia, vaginal burning, postcoital bleeding and urinary symptoms) before and after the treatment and a scale of 0-4 was used. Overall satisfaction was classified with a 5-point Likert scale. All patients had a previous colposcopic evaluation, which revealed VVA and a repeat colposcopy was performed after the treatment. Data were analyzed with SPSS® V24. Results: Mean age was 57.7 years ± 4.5 years old and 11% (3 women) had a background of breast cancer. We obtained a significant improvement in all VVA symptoms except for urinary symptoms. Mean overall satisfaction was 4.0 ± 0.92, with only one patient very dissatisfied with the treatment due to a persistent vulvodynia. Follow up colposcopy showed absence of vaginal atrophy signs in all women. No complications were reported and the treatment was painless in all cases, with no need of any kind of anesthesia. Conclusions: This study suggests that this new treatment modality is safe and effective in the treatment of VVA and may be considered for women with severe VVA who do not respond or have contraindications to hormonal therapy. However the duration of therapeutic effects is not clear and further research is needed.

Transvaginal repair of genital prolapse with a Prolift system: complications and outcomes after 7 years of follow-up

Overview: Transvaginal mesh (TM) procedures has revolutionized the pelvic organ prolapse treatment. Although high success, since 2008 US Food and Drug Administration alert about potential complications that conduct to withdrawn from the market of several mesh systems. Aim: To report long-term outcomes after a polypropylene mesh (Ethicon Gynecare ProliftTM) procedure. Study Design: Cross-Sectional Study Methods: It was performed a retrospective analysis of 54 women submitted to Prolift transvaginal mesh, at Urogynecology department of Centro Hospitalar de Leiria, between January 2009 to January 2017. Outcome was assessed using the Pelvic Organ Prolapse Quantification system and complications were reported with the Prosthesis Complication Classification Code designed by the International Continence Society/International Urogynecological Association. Anatomic failure was defined as recurrent prolapse (grade≥2), at the same compartment. Statistical analysis was performed with STATA 13.1 (significance if p < 0.05). Results: Fifty-four menopausal women were followed at a median time of four years (1-7). Eighty-one percent had more than two vaginal deliveries and 70% were obese (BMI >= 30 kg/m2). Ninety-one percent had POP stage higher than 2. Total mesh was done in 10 patients (19%), isolated anterior mesh in 40 (74%) and isolated posterior mesh in 4 patients (7%). Complications happened in nine patients (17%). We reported five anatomic failures (overall success of 91%). We found statistical association between failure, POP grade and type of mesh repair. (p<0.05). Conclusions: The Prolift transvaginal mesh system seems to be associated with mild complications and a high overall success.

Diagnostic accuracy of sonovaginography for deep infiltrating endometriosis

Objective: The aim of this study was to assess the performance and accuracy of sonovaginography (SVG) for preoperative diagnosis and characterization of deep infiltrating endometriosis (DIE) lesions. Study Design: A prospective study was conducted between January 2014 and January 2016, including all premenopausal women with clinical and/or imaging suspicion of DIE that underwent laparoscopic surgery. We performed consecutive evaluation with transvaginal ultrasound complemented by SVG of all women with clinical suspicion of DIE and assessed for suspected lesions in the anterior compartment (bladder and vesicouterine pouch), rectovaginal septum (RVS), pouch of Douglas (POD), uterosacral ligaments, vagina and rectosigmoid colon. Accuracy of SVG to identify lesions of DIE was assessed for the different sites of DIE, relative to laparoscopic and histological findings. The sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were determined. Results: Fifty nine women were evaluated by SVG and 19 (32%) underwent laparoscopic surgery. Median age was 35 years (range 26-42 years), nine women (47.4%) were nulliparous and five (26.3%) had infertility. Most common symptoms were dysmenorrhea (14/19) and deep dyspareunia (14/19). DIE was confirmed in all patients, 18/19 (94.7%) had involvement of the posterior and 3/19 (8.9%) of the anterior compartments. We found high sensitivity for the diagnosis of lesions involving the POD (92%) and RVS (90%). Our diagnostic sensitivity was lower for DIE lesions involving the anterior compartment (67%), rectosigmoid colon (50%), vagina (50%) and uterosacral ligaments (23%). Conclusions: SVG is a simple, non-invasive method with good diagnostic sensitivity for DIE lesions involving particularly RVS and POD. This technique has a relatively short learning curve for experienced operators and provides an effective alternative to other more invasive and expensive imaging techniques.

Chronic renal disease and gynecology: theoretical review

Overview: The main purpose of this text is to compile in a single article the relationship of chronic renal disease (CRD) with the gynecological pathology. Material and methods: We performed an original articles research on PubMed and Medline with the keywords chronic renal disease, gynaecology, renal transplant and dialysis. Discussion and conclusions: CRD has an important impact in many fields of Gynaecology, as the oncology HPV-related, fertility and menopause. A successful renal transplant seems to be the best way to get improvement in the gynecological disorders of these women.

Pregnancy-associated plasma protein A as a fetal growth restriction marker: what do we know so far?

Fetal growth restriction (FGR) is a challenging complication of pregnancy characterized by severe perinatal morbidity and mortality and long-term adult disease. In this condition, the fetus does not reach his potential growth and is pathologically small. Several biomarkers have been studied as possible predictors of this condition. Pregnancy-associated plasma protein-A stands out as a potential marker of FGR. It is a trophoblast-derived protein involved in the insulin-like growth factor system regulation and thus in the fetal growth. The aim of this review is to assess the current evidence behind the association between this biochemical marker and FGR.

Intraoperative visceral and vascular injuries during total laparoscopic hysterectomy for benign gynaecological disease

Laparoscopic surgery is increasingly being used to perform total hysterectomy in the context of benign gynaecological pathology. When performed by experienced practitioners, it is a safe, effective and reproducible technique, with a high level of patient satisfaction. However, intraoperative complications that may occur are often associated with significant levels of morbidity. Ureter, bladder, bowel and vascular lesions are the main lesions which may arise from performing a total laparoscopic hysterectomy. Thus, it is essential that the surgeon is entirely familiar with the specific methods of prevention, early intraoperative diagnosis and correct therapeutic approach.

Is it really an adnexal ectopic pregnancy?: An atypical presentation

Ectopic pregnancy, a potentially life-threatening condition, represents 1-2% of all pregnancies. Tubal pregnancy represents about 95% of the cases, but other locations can occur such as ovary, uterine cervix and abdominal cavity. Abdominal pregnancy is a rare event, seen in about 1.3% of ectopic pregnancies. We present a case of abdominal pregnancy located at the Douglas pouch and superficially infiltrated the rectovaginal septum in a woman under intra-uterine device contraception.

A 7-year-old girl with vaginal burn from exposure to an alkaline battery

Background: Vaginal burns resulting from alkaline batteries are a rare and potential serious complication which require a prompt intervention. Case: A 7-year-old girl presented to the emergency department with lower abdominal pain, dysuria and brownish vaginal discharge. Clinical history suggested a foreign body. Abdominal radiography showed two alkaline batteries inside the vagina that were removed. Vaginoscopy revealed severe vaginal burns with necrosis of a large area of posterior cul de sac. Two months after the girl was asymptomatic. Discussion: Vaginal foreign bodies should be considered in pre-pubertal girls presenting with vaginal bleeding. Its removal and assessment of direct effects should be immediately performed.

Ruptured subcapsular liver hematoma during pregnancy: a lifesaving multidisciplinary approach

We report a lifesaving multidisciplinary approach to a ruptured subcapsular liver hematoma during the third trimester of pregnancy associated to a HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome. Surgical treatment was performed and both mother and newborn survived. High diagnostic suspicion was crucial to the emergent case management. These patients should be treated in a setting in which adequate supportive care and multidisciplinary teams are available.

Inguinal Schwannoma: case report of a difficult diagnosis

Shwannoma, a typically benign tumor predominant in the cranial pairs, is very rarely found in the inguinal region and poorly described among gynecological tumors. We report the case of a female patient with inguinal mass and the difficulties of the diagnosis of tumors in this region, showing the complexity and importance of the appropriate propaedeutic.

Fetal intra-abdominal umbilical vein varix

Fetal umbilical intra-abdominal vein varix is a rare congenital malformation characterized by focal dilatation of the umbilical vein. It's clinical significance is unclear and is usually an isolated finding, in some cases it may be associated with other fetal anomalies, chromosomal defects or fetal death. The authors report a case of pregnant woman at 25 weeks of gestation with a fetus affected by dilatation of an intraabdominal portion of the umbilical vein, with a favorable progress and outcome.

Adnexal masses: a true challenge

Preoperative diagnosis of adnexal masses is still one of the greatest challenges for gynaecologists. Even though the majority of adnexal neoformations are benign, a careful evaluation to exclude malignancy is mandatory. The rapid evolution in the field of ultrasonography increased diagnostic accuracy and magnetic resonance imaging provides a valid contribution, but still, sometimes, the distinction between malignant and benign is difficult. We report a case of a premenopausal women who presented with a large and painful abdominal mass four months after an emergent caesarean delivery.

Placenta accreta: about the need for a reference center

Evaluation of fetal death after 24 weeks