Acta Obstétrica e Ginecológica Portuguesa

A look at the present state of the Portuguese technical and scientific activity in Gynecology and Obstetrics

Total laparoscopic hysterectomy: impact of body mass index on outcomes

Overview and aims: Hysterectomy is one of the most common gynecological surgical procedures and several studies have demonstrated the multiple advantages of laparoscopic approach in general. Obesity was initially considered to be a contraindication for laparoscopy. However, this historical perspective has been disputed. The aim of this study was to assess the effect of the body mass index (BMI) on intra-operative parameters and intra and post-operative complication rates of total laparoscopic hysterectomy (TLH). Study design: A retrospective, observational, descriptive and analytic study. Population : All TLH performed in our department, by the same surgical team, between April 2009 and March 2014, were evaluated. Methods : Medical records were reviewed for patient characteristics (BMI, age, medical and surgical history), surgical characteristics (surgical indication and concomitant procedure, uterine weight, operating time, post-operative hemoglobin variation, length of hospital stay), and intra and post-operative complications. The data were analyzed according to patients' BMI. Results: The study population was divided in normal BMI (n=145), overweight (n=119) and obese (n=54). Obese patients were older, more frequently postmenopausal and with more medical pathology than normal BMI patients. More than 50% of the patients had history of at least one previous abdominopelvic surgery with no differences among the groups. No significant differences were found in terms of uterine weight (217.7 ± 154.8 vs. 257.5 ± 176.1 vs. 225.4 ± 151.0 g; p> 0.05), post-operative hospital stay (1.6 ± 0.9 vs. 1.5 ± 1.0 vs. 1.5 ± 0.9 days; p> 0.05), operating time (72.2 ± 25.3 vs.77.5 ± 25.8 vs. 83.6 ± 35.3 minutes; p> 0.05) or complication rates (12.4% vs. 14.3% vs. 13.0%). Conclusions: This study demonstrates that, in qualified hands, obesity did not increase the operating time and the intra or post-operative complication rates associated with TLH. Thus, high BMI should not be considered a contraindication for this procedure.

First trimester prediction of pre-eclampsia in low risk pregnancies: determining the cut-off in a portuguese group

Objective: We aimed to identify the cut-off for risk of pre-eclampsia (PE) in Portuguese population by applying the first trimester prediction model from Fetal Medicine Foundation (FMF) in a prospective enrolled cohort of low risk pregnant women. Population and methods: A prospective cohort of low risk singleton pregnancies underwent routine first-trimester screening from 2011 through 2013. Maternal characteristics, blood pressure, uterine artery Doppler, levels of pregnancy-associated plasma protein-A (PAPP-A) and free b-human chorionic gonadotropin were evaluated. The prediction of PE in first trimester was calculated through software Astraia, the outcome obtained from medical records and the cutoff value was subsequently calculated. Results: Of the 273 enrolled patients, 7 (2.6%) developed PE. In first trimester women who developed PE presented higher uterine arteries resistance, represented by higher values of lowest and mean uterine pulsatility index, p <0.005. There was no statistical significance among the remaining maternal characteristics, body mass index, blood pressure and PAPP-A. Using the FMF first trimester PE algorithm, an ideal cut-off of 0.045 (1/22) would correctly detect 71% women who developed PE for a 12% false positive rate and a likelihood ratio of 12.98 (area under the curve: 0.69; confidence interval 95%: 0.39-0.99). By applying the reported cutoff to our cohort, we would obtain 71.4% true positives, 88.3% true negatives, 11.4% false positives and 28.6% false negatives. Conclusion: By applying a first trimester PE prediction model to low risk pregnancies derived from a Portuguese population, a significant proportion of patients would have been predicted as high risk. New larger studies are required to confirm the present findings.

Amniocentesis in a tertiary referral centre: still the same old story?

Overview and Aims: The main objective of this study was to describe the main clinical indications, diagnostic yield, complications and pregnancy outcomes regarding amniocentesis performed in a tertiary University Hospital, during an 8-year period. Study Design: We developed an observational, retrospective study, of all amniocenteses performed between June 2003 and June 2011. Population: All pregnant women consecutively submitted to amniocentesis in a tertiary University Hospital between June 2003 and June 2011. Only singleton gestations were included. Methods: We searched the database of the Genetics Department for all products obtained by invasive procedures performed during pregnancy between June 2003 and June 2011, in order to identify the amniocenteses performed during that period. Maternal demographics, indication for amniocentesis, gestational age at the time of amniocentesis, procedure-related complications during pregnancy and pregnancy outcome data were extracted from patient's physical and electronic medical records. Results: A total of 1358 amniocenteses were included in the study. The proportion of amniocentesis performed due to maternal age decreased significantly and due to positive prenatal screening significantly increased over time (p<0,001).The indication with highest positive predictive value regarding abnormal fetal karyotype was parent carrier of chromosome abnormality (46.2%). Total pregnancy loss was 1.6%, post-procedural miscarriage rate was 0.74% and fetal loss risk within 2-weeks of procedure was 0.4%. There was no association between fetal loss and operator, number of needle insertions, transplacental puncture and bloody tap. Conclusions: Counselling is complex and questions regarding procedure-related complications and fetal loss have been inconsistently reported. National and local institutional precise estimates are important to consider when advising women requesting amniocentesis.

Therapeutic procedures in the treatment of condylomata acuminata

Genital condylomata acuminata (CA) are common, sexually transmitted lesions, caused most often by the human papilloma virus (HPV) types 6 and 11. They affect both females and males and occur in all regions of the anogenital area. Conventional treatment, often involving repeated local drug application or invasive methods, has not been definitively demonstrated to be effective in eliminating CA lesions and preventing them from recurring. This review summarizes the current literature on epidemiology, transmission and diagnosisof CA with special focus in the treatment.

«Intimate surgery»: what is done and under which scientific bases?

Aesthetic vulvar and vaginal surgery have been increasing in the last few years. The same procedure can be found under several designations, as well as different designations might refer to the same procedure. Despite the increasing number of patients seeking these procedures, there is a lack of scientific basis for the performance of most of it, as well as of good follow-up studies in terms of complications. It is important to distinguish cases of plastic surgery needed for the treatment of vulvar lesions or correction of symptomatic hypertrophic labia minora, pelvic organs prolapse or urinary incontinence from pure aesthetic surgery, just to pursue a sometimes unrealistic model of perfection. Despite the easiness of performance of most of these procedures, the chance of complications must always be kept in mind. A psychological evaluation of the women candidate to genital aesthetic surgery should be considered in most cases.

Gastroschisis: timing and route of delivery

Gastroschisis is a congenital abdominal wall defect in which bowel and other abdominal contents are herniated. The eviscerated loops are directly exposed to amniotic fluid which causes intestinal damage and neonatal mortality. Unless there is an obstetrical contraindication, delivery timing of gastroschisis foetuses should be extended at least to 37 weeks of gestation. Early elective delivery may result in prolonged time to enteral feeding and length of hospital stay as well as prematurity-related complications. There is no evidence that vaginal delivery results in additional morbidity in gastroschisis foetuses and caesarean section is recommended only for obstetrical indications.

Obstetric outcomes after radical trachelectomy in a series of four pregnancies

Vaginal radical trachelectomy has been established as a valuable fertility-preserving treatment in women with early stage cervical cancer. Pregnancies after this procedure may pose several clinical challenges. The aim of this study was to report pregnancy outcomes after vaginal radical trachelectomy. We surveilled four pregnancies in three different patients. No first trimester miscarriages were observed. One of the patients suffered a second trimester pregnancy loss as a consequence of a preterm premature rupture of membranes. A total of three pregnancies reached the third trimester, and one delivered prematurely, at 29 weeks of gestation. A caesarean section was performed in all cases that reached viability. Good maternal and neonatal outcomes are possible in pregnancies after radical trachelectomy. Obstetrical surveillance must be undertaken in a maternal-fetal unit included in a tertiary hospital, in order to achieve the best results.

A didelphic uterus and imperforate hymen presenting as a double hematometrocolpos: a case report

The rare finding of both a didelphic uterus and imperforate hymen is described in this case. Imperforate hymen is an important cause of abdominal pain in female adolescents, which can usually be diagnosed by thorough clinical history and physical examination. Further investigation may be necessary to exclude other genital tract anomalies.

Acute iron intoxication in pregnancy: case report

Acute intentional iron intoxication is an unusual scenario in the Obstetrics Emergency Department. However, it is the second most common overdose in pregnancy and it is associated with severe morbidity and mortality. We present a case of a 30-week pregnant woman with potential severe iron intoxication in the context of a suicide attempt.

Villar's Nodulle: a rare case report

Endometriosis is defined as endometrial tissue outside the uterine cavity. Pelvic locations of the disease are more prevalent, but it also occurs in many extra-pelvic locations. Abdominal wall endometriosis is usually associated with the presence of scars, more often after cesarean or histerectomy (secondary abdominal wall endometriosis). Primary abdominal wall endometriosis is a rare condition, and occurs in patients with no abdominal scars. We present a case of a 44-year-old woman, nulliparous, with no personal history of abdominal surgery. She complained of an umbilical mass with 3,5cm which was painful and had a bloody drainage during menses. She underwent surgery with excision of the mass. The pathology findings of endometrial glands and stroma confirmed the clinical assumption of endometriosis. Inspection of the pelvis showed no pelvic endometriosis.

First trimester ultrasound detection of fetal micrognathia

Fetal micrognathia is a rare ocurrence in which there is a small mandible and a receding chin. It can be seen in the sagital view of the face during an obstetric ultrasound and it may be associated with adverse environmental factors, multiple genetic syndromes and with chromosomal abnormalities. The overall prognosis seems to be poor. We present a case of isolated fetal micrognathia, which has been suspected in the first trimester ultrasound and ended in termination of pregnancy.