Acta Obstétrica e Ginecológica Portuguesa

Residents, Hysterectomies and Medical Education

Referral hospitals: Do we need them?

Referral Centers for particular situations are necessary and an added value for Nacional Obstetrics. Centers for fetal therapy and for management of placenta accreta spectrum disorders are a good example of this need. Creating teams with experience is the only way to answer to the challenges that Modern Obstetrics poses to us.

Influence of maternal age on caesarean delivery: experience in a tertiary hospital

Caesarian section (C-section) is a worrisome issue due to its increasing incidence and associated risks, especially in low risk pregnancies. Maternal age has an increasing tendency in modern societies and appears to be contributing to the rise in the Csection rates - due to co-morbidities, "high risk labeling" or an intrinsic biological cause related to aging. Our aim is to evaluate the association between maternal age and delivery mode in low risk pregnancies. Retrospective observational study using electronic medical records, ICD-9-CM coding system and unit database software Obscare. Data from low risk singleton term labors occurred from January 2008 to December 2012 was included. We assessed 10411 cases, divided in three age groups (<20, 20-34, ≥35 years old) - women with 20 to 34 years old were considered the reference group. Parity, presentation, delivery mode, induction, C-section indication and timing were assessed. Women with ≥35 years old have a higher probability of C-section, 30.7% vs. 22.3%, OR 1.527 [1.371-1.700]. This odd remains higher in non-induced labors, OR 1.367 [1.221-1.531], but loses its significance in the subset of only induced labors. In both multiparous and nulliparous the probability of C-section remains higher for women >35 years old, OR 1.581 [1.356-1.843] and 2.098 [1.742-2.527]. This age group has a higher probability of having a C-section due to "previous C-section" OR 3.121 [2.519-3.865], and a lower probability due to "labor arrest" and "non-reassuring fetal tracing", OR .559 [.457-.685] and .724 [.563-.931], respectively. For the older group, the odd of having an elective C-section was higher, OR 1.844 [1.509-2.254] and of having an urgent C-section lower, OR, .644 [.537-.774]. Older women have a higher probability of having a C-section, even in the absence of identifiable comorbidities. Elective interventions and previous C-sections seem to play a crucial role in this association.

Guidelines for preterm labour management: a comparative analysis of the Portuguese national reality

Overview and Aims: Preterm labour (PTL) represents 7-8% of all Portuguese labours. Its management is marked by ongoing controversies, resulting in systematic variability in management in different institutions. We present an assessment of agreement among national and international PTL management guidelines. Methods: A search for PTL management guidelines was performed. The following contents were extracted: Definition of Threatened PTL (TPTL) or Established (EPTL), Prevention, Diagnosis, Tocolysis, Fetal Lung Maturation and Neuroprotection. An interguideline agreement analysis was performed using a consensus obtained through a modified Delphi approach. A score of 1, 0.5 or 0 was given, for "agreement" (similar clinical significance), "partial disagreement" (differences with possible clinical significance) and "disagreement" (differences with clinical significance), respectively. Median inter-guideline agreement scores (MCct) and inter-observer Proportions of Agreement were calculated. Results: Five national protocols fulfilled selection criteria. Four international guidelines were also considered: WHO, ACOG, NICE and European Association of Perinatal Medicine. Nationwide, more significant inter-guideline disagreements related to definition of EPTL, Prevention and Diagnosis, with MCct of 0,25. TPTL, Tocolysis, Fetal Pulmonary Maturation and Neuroprotection were similarly agreeing, with MCct of 0,5. In international guidelines only four clinical categories were analyzed, with Neuroprotection achieving a MCct of 0,75; EPTL and Pulmonary Maturation reaching a MCct of 0,25; and Tocolysis presenting the lowest MCct of 0,00. Discussion: There are differences among the PTL management guidelines published internationally and in Portugal that may have clinical significance. Further research is warranted to evaluate the potential for assembling a wider national consensus through more explicit health policies.

Reasons for interrupting hormonal contraception in a region of Portugal

Overview and Aims: Due to the scarcity of available information in Portugal in relation to the number of women who use and discontinue hormonal contraceptives, the aim of this study was to evaluate the factors associated with this behaviour. Study Design: The study population was drawn from seven primary health care units and consisted of 329 women between the ages of 18 to 45, who were users of those units. We estimated the overall proportion of past and current use of hormonal contraceptives. We then calculated the discontinuation rates and analysed the reasons for stopping and switching contraceptive methods. Population: Women between 18 and 45 years. Methods: Study participants anonymously completed a self-report questionnaire. The questionnaire included information on: age, marital status, educational level, and obstetric history (number of pregnancies, abortions [spontaneous and induced], number of live childbirths). All hormonal contraceptive methods available in Portugal at the time were shown, with generic and trade names. Results and Conclusions: Overall, 58.4% reported discontinuing at least one contraceptive method. The main reasons for the discontinuation were an adverse drug reaction (25.3%) and contraindication or medical advice (23.6%). The majority (71%) of adverse drug reactions began within the first year of usage and the main ones were headache (31.7%) and oligomenorrhea or amenorrhea (28.3%). Knowing the exact reasons why women abandon a contraceptive method is of the highest importance in improving contraceptive compliance. Medical doctors rely on this information to design counselling strategies and to provide the methods most widely used and accepted by women.

Paradigm shift in hysterectomies: a retrospective comparative study

Overview: Despite the reduction in the rate of hysterectomies during the past years, it is still the second most common major surgical procedure performed among women. It has been common practice to counsel women who were planning hysterectomy, particularly in their mid-40s or older, to undergo concomitant bilateral salpingo-oophorectomy. However, this recommendation is now being replaced by consideration of ovarian conservation with bilateral salpingectomy (BS). Aims: To describe the trends regarding hysterectomies and concomitant adnexal surgery. Study Design: Single-center retrospective comparative study. Population: Women who underwent hysterectomy (2004 versus 2014). Methods: Data were analysed using STATA 13.1. Results: The overall number of hysterectomies decreased 28.5% (n=916 versus n=656). There was a change in the pattern of indications for hysterectomy: benign pathology decreased [79.4% versus 64.5% (p<0.001)] (mainly due to uterine fibroids) with a corresponding increase in hysterectomies due to urogenital prolapse [13.7% versus 23.6% p<0.001)] and malignant pathology [7.0% versus 11.9% (p<0.01)]. Regarding the surgical approach, there was a decrease in laparotomic route (80.9% versus 57.4% (p <0.001) with an increase in the vaginal [12.6% versus 28.7% (p<0.001)] and laparoscopic routes [6.6% versus 13.9% (p<0.001)]. In women with benign pathology, the rate of bilateral adnexectomy decreased from 69.4% to 53.3% (p<0.001) and the rate of BS increased from 0.9% to 16.5% (p<0.001). There was a reduction in intraoperative complications [4.3% versus 1.8% (p=0.006)], immediate postoperative complications [11.6% versus 7.0% (p=0.003)] and duration of hospitalizations [5.6±3.0 versus 4.1±2.4 days (p<0.001)]. Conclusion: The rate of hysterectomies decreased in the last decade, mainly due to the reduction in hysterectomies for uterine fibroids. We verified a significant shift towards ovarian conservation with increasingly concomitant BS. Considering ovarian carcinogenesis, the increase in prophylactic BS may have future impact on the reduction of ovarian cancer.

Prenatal diagnosis of neural tube defects

Neural Tube Defects (NTD) constitute a heterogeneous group of congenital malformations which includes: anencephaly, cephalocele and spina bifida. The 2D and 3D ultrasound techniques along with the magnetic resonance imaging have been used to identify and characterize the majority of clinical relevant lesions. Meningomyelocele - the most frequent NTD - has been increasingly managed through fetal surgery, with promising results. This article pretends to review updated information about prenatal diagnosis and management of NTDs.

Fetal aortic stenosis: surviving on the edge

Aortic valve stenosis is a congenital heart disease with an estimated prevalence at birth of 0.22/1.000 worldwide. During intrauterine life it can progress unfavorably, affecting newborn survival and his cardiovascular development. Fetal echocardiography is an important tool in the diagnosis of this condition and its various manifestations, allowing adequate planning. Its evolution in utero is complex and places difficult clinical decisions. We report the case of a patient with prenatal diagnosis of severe aortic stenosis, and demonstrate the complex clinical follow-up of these situations.

Congenital chylothorax: a case report

Congenital chylotorax is the most common form of pleural effusion in the prenatal period, although it is rare. The etiology of this condition isn't clear, but it is thought to be related to congenital malformations of the lymphatic system. The overall mortality rate is 25%-50%, but it could be higher. Congenital chylotorax complicated with hydrops in a premature newborn is an uncommon and serious clinical problem. We report a case of a congenital bilateral chylothorax with early and severe prenatal presentation. The outcome was bad, with neonatal death, despite all the efforts in his management.

Bilateral massive vulvar edema and thyroid dysfunction in ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) can be a serious condition. There are very few cases described of massive vulvar edema in OHSS. Ovarian hyperstimulation can also have an important impact on thyroid function. We present a case of severe OHSS, massive vulvar edema and severe thyroid dysfunction in a young woman with a congenital hypothyroidism submitted to a second IVF cycle for anovulation. The particularities of this case are related to the fact that it had severe and rare complications, even being a second IVF cycle, conducted in the same way as the previous one, in which there was no pregnancy.

Spina bifida detection in first trimester ultrasound

Spina bifida is one of the most common severe congenital defects of the central nervous system. Prenatal diagnosis is currently performed in second trimester. First trimester diagnosis is rare and can be challenging, but it can be suspected in the absence of intracranial translucency. We report images of a case of spina bifida detected at 13 weeks scan. The fetus presented images suggestive of open spina bifida and intracranial translucency was absent, also the crown-rump length evolution in serial ultrasound examinations was deficient. At 16 weeks a spontaneous abortion occurred and the histopathology analysis confirmed the diagnosis of spina bifida.

Carcinoma do endométrio e estadiamento cirúrgico: ressonância magnética ou estudo extemporâneo?