Acta Obstétrica e Ginecológica Portuguesa

Autophagy in obstetrics and gynecology

What's the role of routine hysteroscopy prior to the first assisted reproductive technique?

Overview: Integrity of the uterine cavity is critical to embryonic implantation and it is mandatory to evaluation it in the routine investigation of infertility. Hysteroscopy is considered the gold standard, allowing concomitant treatment , which optimizes the conditions for future embryo transfers. Nevertheless, controversies still exist in its routine performance prior to the first assisted reproductive technique. Aims: To assess the concordance between the findings of transvaginal ultrasonography and hysteroscopy and to investigate risk factors for intracavitary pathology. Study Design: Retrospective observational study. Population: 104 women submitted to transvaginal ultrasonographic evaluation (with normal uterine cavity evaluation) and hysteroscopy before the first assisted reproductive technique. Methods: A database was constructed through the analysis of each patient's file. Descriptive and inferential statistical analysis was performed with Statistical Package for Social Sciences, version 20.0. P ≤0,05 was considered statistically significant. Results: The study group had a mean age of 33,3 years and a mean duration of infertility of 45,6 months. About 87% patients had primary infertility. Hysteroscopy revealed intracavitary alterations in 20 women. In 6 patients a simultaneous surgical procedure was performed and 4 had an alteration of the therapeutic plan. No complications were documented. Descriptive analysis revealed that uterine abnormalities observed in hysteroscopy were significantly more frequent in women aged ≥ 35years (35,1 vs 32,8%, p=0,008). In the logistic regression it was observed that hysteroscopic alterations were significantly and positively associated with female age ≥35years (OR=2,85; IC95%: 1,1-7,7). Conclusions: Ultrasound findings were not consistent with hysteroscopic findings in 19,23% patients, and this was more frequent in women aged ≥35years. Hysteroscopy has a special role in the investigation of infertility, mainly in populations with risk factors for intracavitary anomaly and its impact should be reassessed.

Perception of pain in office hysteroscopy

Overview and Aims: The aim of our study was to evaluate which variables are able to influence the perception of pain during office hysteroscopy. Study Design: A prospective observational study was carried out. Population: Two hundred and sixty six women who underwent a total of 288 office hysteroscopies between February 2012 and August 2014. Methods: After the procedure, all patients were asked to complete a questionnaire using a 0-10 pain scale. Results: The mean pain level was 4.04 and the mean duration of the procedure was 24.88 minutes. Hysteroscopic anesthesia was used in 74 out of a total of 288 procedures. The duration of the procedure was directly related to the pain levels recorded by the patients (p<0.01). The presence of cervical stenosis also contributed for higher levels of pain (p<0.05) and a prior vaginal delivery was a protective factor. The postmenopausal status, use of misoprostol and the histeroscopist experience didn't influence the level of pain. Conclusion: The duration of procedure and the presence of cervical stenosis were significantly related to higher levels of pain during office hysteroscopy.

Office hysteroscopy: cost analysis

Overview: The office “see and treat” hysteroscopy has become to some authors the gold standard for the diagnosis and treatment of intrauterine pathology. It is associated with lower costs and greater safety for the patient. However, this model can be limited by the patient's discomfort or pain, due to the lack of analgesia and by the dimensions of the mass that are removed. Study objective: To compare the costs of office hysteroscopy with ambulatory hysteroscopy within a public and a private institution. Methods: In the public hospital calculus were carried out by using DRG (“DiagnosisRelated Group”) tables. In the private health unit, calculations were made according to the insurance company tables, assuming an average cost to the healthcare provider. A comparison between the three surgical hysteroscopy models was performed. Results and Conclusions: The costs associated with the procedure are different in the public hospital and private institutions. However, the model of office hysteroscopy, in both systems, has shown to be associated with significantly lower costs.

Short and long acting reversible contraceptive methods: observational study

Overview: The daily pill, a short-acting reversible contraceptive (SARC), is more used than long-acting reversible contraceptives (LARC) though these are highly effective, safe and less dependent on women use. It is important to identify which differences between SARC or LARC users can justify this choice. Aims: Describe and compare the two types of contraceptive methods users (age, marital status, previous history of pregnancy, level of education, age at which the method was started, level and source of knowledge, medical advice and level of satisfaction with the information received). As a secondary objective, we aimed to identify the existence of myths and misbeliefs about contraception and the reasons for choosing or discontinuation of the contraceptive method. Study Design: Observational and retrospective. Population: Women who use or had used contraception, aged 18 -50 years. Methods: A self-report and anonymous questionnaire, available in primary health care centers and hospitals. Results: In a group of 300 women, with a median of 35,6 years (18 - 50 years; s = 8,3 years), 68% (203/300) were using a contraceptive method and 28% (83/300) were no longer using it . Among these, 75% were using SARC or these corresponded to the last method used. Single women prevailed in the SARC group (p=0,002) and those with a previous pregnancy prevailed in the LARC group (p=0,002). No other statistically significant differences were identified. 86% (237/274) had a medical consultation before beginning to use a contraceptive, and 59% (139/237) were very satisfied with the information received. The control of the menstrual cycle was important for SARC users whether the using facility was important for LARC users. Conclusions: Although effective and safe, LARC where less prevalent in our study. History of previous pregnancy was the only clinically significant difference between SARC and LARC users

Ovarian reserve markers and antral follicle count

Ovarian reserve plays a crucial role in achieving pregnancy following any treatment in subfertile women. The estimation of ovarian reserve is routinely performed through various ovarian reserve tests. These tests include hormonal parameters and those using exogenous hormones and transvaginal pelvic ultrasound. However, their reliability is variable. Recently, anti-Müllerian hormone emerged as a promising marker of ovarian reserve. In this paper we revise the role of hormonal basal, dynamic tests and ultrasonographic parameters as ovarian reserve markers, focusing on their interpretation, potential advantages and risks in order to provide its applicability to gynecological practice

Desquamative inflammatory vaginitis

Desquamative inflammatory vaginitis (DIV) is a well characterized clinical syndrome of unknown aetiology and pathogenesis. It presents as a diffuse exudative vaginitis, with pain, profuse purulent discharge and epithelial cells exfoliation. Diagnosis is often difficult, since it shares several characteristics with other vulvovaginal inflammatory disorders. Wet mount plays a key role, presenting a marked increase in leukocytes and parabasal cells; pH is elevated (>4.5). The exclusion of other causes of purulent vaginitis is mandatory for the diagnosis. Although the treatment can be a challenge, often requiring maintenance since relapse is common, good results are described with topical clindamycin and corticosteroids.

Pregnancy, mechanical heart valves and warfarin: 3 cases, 3 outcomes

The authors describe three cases of women who became pregnant despite having a mechanical heart valve requiring chronic anticoagulation with warfarin. Their outcomes are described and anticoagulation management during pregnancy is discussed.

Giant placental chorioangioma and polyhydramnios

Chorioangioma is the most common benign tumor of the placenta, occurring in 1% of all pregnancies. Small chorioangiomas tend to remain asymptomatic. Giant chorioangiomas have been associated with a number of severe fetal complications and high perinatal mortality. We report a case of a giant chorioangioma diagnosed in the third trimester of pregnancy. The size of tumor and the amniotic fluid index increased from the time of diagnosis to the end of pregnancy. A term labour was uncomplicated and a healthy newborn was delivered. Macroscopic and microscopic examination of the placenta was consistent with placental chorioangioma.

Ovarian steroid cell tumor not otherwise specified with virilizing manifestations: case report

Androgen-secreting tumors are present in about 0.2% of women with hyperandrogenism and more than half are malignant. Steroid cell tumors account for less than 0.1% of all ovarian tumors. The average age of presentation is 43 years, with androgenic clinical features in 56-77% of cases. The authors report a case of a 21-year-old female with virilization signs and a large ovarian mass, submitted to right salpingo-oophorectomy. Histopathologic examination revealed an ovarian steroid cell tumor not otherwise specified. A close surveillance is required attending that approximately one third of these tumors are malignant and little is known about their behavior.

Prenatal diagnosis of sacrococcygeal teratoma

Sacrococcygeal teratoma (SCT) is the most common congenital tumor, with an incidence of 1:40,000 live births. It originates from multipotential embryonic stem cells and most tumors arise from the anterior surface of the sacrum or coccyx. On ultrasound, SCT presents as a heterogeneous mass of variable size that stands out from the sacrococcygeal region. Here we present a picture of a SCT detected at the 20-22 weeks ultrasound examination in our institution. The fetus, who had a normal ultrasound examination at 13 weeks, also presented other characteristics suggesting this diagnosis, later confirmed by an histopathological analysis.