Acta Obstétrica e Ginecológica Portuguesa

Changing times

The naturalistic delivery from a law perspective: the pregnant/fetus conflict

There is a growing number of pregnant women who want a decrease of medical intervention in childbirth. This article highlights some of the ethical and legal problems that this posture can pose to the medical team, especially in cases where the decision of the pregnant woman may jeopardize the health or life of the fetus.

Association between biochemical screening for fetal aneuploidy in the first trimester and adverse obstetric outcomes

Overview: The first trimester screening for fetal aneuploidy includes a combined evaluation of maternal age, obstetric history, ultrasound and biochemical markers. Variations in maternal serum levels of biochemical markers (free b-hCG and PAPP-A) have been associated with adverse obstetric outcomes, even in the absence of aneuploidy. This study aimed to evaluate the association of PAPP-A and free b-hCG with the occurrence of adverse obstetric outcomes, in an obstetric population with negative first trimester screening for chromosomal abnormalities. Study design: Observational, descriptive, analytic and retrospective study that included 1128 pregnancies with a negative first trimester screening, in 2013. Delivery occurred in our Hospital. Methods: The levels of both biochemical markers (free b-hCG and PAPP-A) were compared between groups with a given adverse obstetric outcome and women without any adverse event. Binary logistic regression and multiple linear regression analysis were performed to determine if free b-hCG and PAPP-A were important predictors for adverse outcomes. Results: Maternal serum levels of PAPP-A were significantly lower in women who developed pre-eclampsia compared to women without any adverse obstetric outcome (0.98±0.2 vs. 1.18±0.63 MoM; p=0.027). Maternal serum free b-hCG was significantly lower in pregnant women who had birth before 37 weeks of gestation, compared to pregnant women with a term birth (median; interquartile range: 0.78; 0.39 vs.0.94; 0.75 MoM; p=0.037). Linear regression analysis showed that PAPP-A is an independent predictor of fetal birth weight and that free b- hCG is a predictor of fetal gestational age at birth. Conclusion: Serum PAPP-A and free â-hCG in the first trimester are significantly reduced in pregnancies, with a negative first trimester combined screening for fetal aneuploidy, who developed pre-eclampsia and had a preterm delivery, respectively. In these populations, for a better risk assessment, we suggest to perform pre-eclampsia and preterm labour screening.

Cervical adenocarcinoma in situ: factors associated with residual lesion after cone biopsy

Overview and Aims: The currently accepted treatment for cervical adenocarcinoma in situ is total hysterectomy. However, considering this is a condition that frequently affects young women, the safety of a conservative treatment in selected cases is under investigation. This study aimed to evaluate the factors possibly associated with the presence of residual lesion in patients undergoing conization for adenocarcinoma in situ of the cervix. Study Design: Retrospective observational study. Population and Methods: Analysis of factors possibly associated with the presence of residual tumor in 72 patients submitted to conization for adenocarcinoma in situ of the cervix from January 1993 to December 2012. Results: Forty-six of the 72 patients were included in the analysis. In 19 cases (41%) involvement of conization margins was confirmed; the endocervical study was conducted on 37 cases (80.4%) and revealed adenocarcinoma in situ in 7 cases (18.9%). When analyzed separately, the positive predictive value of the endocervical study was higher than the involvement of conization margins (85.7% vs 52.6%). When both factors were combined, it was found that when both were negative, no residual tumor was identified; positivity of both corresponded, in all cases, to the presence of residual lesion. Statistically significant difference was found between the two groups (with and without residual AIS) regarding margin involvement and the endocervical study (p < 0,05). Conclusion: This study confirms and reinforces the idea that a conservative approach can be considered in selected cases of patients wishing to preserve fertility, considering the margins of cone biopsy and the endocervical study are both negative. However, these patients should be maintained in surveillance and a definitive treatment should be recommended after completion of the reproductive project.

Shoulder dystocia: obstetric maneuvers and its morbidity

Introduction: Shoulder dystocia (SD) is known for being an unpredictable and unpreventable event associated to substantial morbidity to the mother and neonate. The aim of this study was to determine the incidence of SD in a tertiary care hospital and the morbidity according to the type of maneuvers (McRoberts' maneuver and suprapubic pressure versus rotational maneuvers or delivery of the posterior arm) used to resolve the dystocia. Methods: This was a prospective cohort study of pregnancies complicated with SD carried during two years and a half. Maternal characteristics, duration of second stage of labor, type of delivery, fetal weight, neonatal morbidity (Apgar score <7 at 1st minute, type of injury, neonatal intensive care unit admission) and maternal morbidity (3rd or 4th degree laceration, cervical tear, post-partum hemoglobin < 8g/dL, perineal haematoma, post-partum fever, dehiscence of episiotomy) were collected. According to the maneuver performed, data were compared using Chi-square test, Fischer exact test or Student t test, as appropriate. A p-value of < 0,05 was considered significant. Results: During the study period 123 (3.3%) pregnancies were complicated with SD. Baseline patient characteristics for age, parity, BMI, weight gain did not vary significantly according to type of maneuver. Rotational maneuvers and delivery of the posterior arm were associated to longer second stage of labour (60 min vs 45 min), higher proportion of instruments applied in a transverse fetal head position (30%) and increased neonatal (45%) and maternal (27%) morbidity. Conclusion: Although rare, SD is associated to increased neonatal and maternal morbidity, specifically when rotational maneuvers and delivery of posterior arm are used.

Fetal drug therapy

Fetal drug therapy can be defined as the administration of specific drugs, with the aim of treating any fetal pathology, seeking the improvement of long-term perinatal results. This review will provide updated information about some fetal pharmacologic therapies that are exclusively destined to the treatment of fetal pathologies, which don't include any mother's issues that require simultaneous treatment.

Type and surgical approach in hysterectomy and lesions to the urinary tract

Hysterectomy is the second most frequently performed gynecological surgery. It is therefore relevant to perform an assessment of factors associated with urological surgical morbidity. Hysterectomy is associated with injuries to the ureter (0-3.97%) and bladder (0-2.8%). The incidence of urologic complications has been declining, as well as the difference between surgical approaches. There are some studies that demonstrate an increased risk of urologic injuries with laparoscopic and radical hysterectomy. Controversy remains on which are the real benefits of subtotal hysterectomy. No differences were found between intrafascial and extrafascial techniques. Concomitant salpingophorectomy doesn't lead to a greater risk of injuries.

Transient osteoporosis of pregnancy: two cases in twin gestation

Transient osteoporosis of pregnancy (TOP) is a medical condition, self-limited, infrequent, occurring in women in the third trimester of pregnancy or immediate postpartum, usually affecting the joints of the lower limb, specially the hip joint, typically resolving within a few months after delivery. Radiographic studies describe loss of bone mass and edema in affected portion. We describe 2 cases of primigravid women, twin gestation with hip pain during the third trimester, who were diagnosed TOP by magnetic resonance. These women had a good clinical and analytical response to the instituted measures with a complete return to daily activities months after delivery.

Peritoneal tuberculosis: diagnostic challenge for the gynecologist

Peritoneal tuberculosis is an uncommon form of extra-pulmonary tuberculosis. A 53-year-old female presented with weight loss, fever and abdominal pain with abnormal vaginal discharge. On physical examination rebound lower abdominal tenderness, leucorrhoea and painful cervical motion were noted. Intravenous antibiotics were started, assuming the diagnosis of pelvic inflammatory disease, without clinical improvement and a pelvic MRI was done that showed signs consistent with peritoneal carcinomatosis. Surgical peritoneal biopsies showed multiple granulomas with central necrosis. Tuberculosis treatment was started with clinical improvement. Among suspicious cases peritoneal biopsies are essential to confirm the diagnosis of peritoneal tuberculosis.