Acta Obstétrica e Ginecológica Portuguesa

Guidelines para monitorização fetal intraparto: resumo do novo consenso da FIGO de 2015

Cardiotocography (CTG) is a common technology used for intrapartum care. Since its introduction in obstetrics several classifications have been published for CTG interpretation. The first international consensus on fetal monitoring was published in 1987 by FIGO. The document has become outdated and in 2015 new guidelines on intrapartum fetal monitoring have been published by a consensus panel of 46 experts. These new guidelines include five chapters: introduction, physiology of fetal oxygenation and the main goals of intrapartum cardiotocography, intermittent auscultation and adjunctive technologies. This article summarizes the main aspects of each of these chapters.

Alterações à classificação da dor vulvar persistente: (vulvodinia)

The classification of vulvodynia has been recently revised. This article highlights the main changes that were introduced: for the first time, a minimum duration of symptoms (3 months) was included in the definition; women with other vulvar conditions (e.g. lichen sclerosus) are no longer excluded from a possible diagnosis of vulvodynia; a list of possible associated factors was added to the document; new discriminators were included (onset and temporal pattern) and the term "non-provoked vulvodynia" was replaced by "spontaneous vulvodynia".

Tratamento cirúrgico da endometriose profunda: série de 16 casos

Overview and aims: Deep endometriosis is defined as the presence of infiltrating lesions more than 5mm deep to the peritoneum and it corresponds to 5-10% of all endometriotic lesions. Laparoscopy is considered the gold standard for the diagnosis and treatment of endometriosis and it is successful in controlling pain, decreasing recurrence rates and improving fertility. This study aims to evaluate the work of a Laparoscopic unit specialized in the treatment of endometriosis. Study design, Population and Methods: Retrospective study of all laparoscopies performed for deep endometriosis between January 2013 and December 2014. Clinical presentation, pre-operatory exams, intra and post-operatory surgical data and follow-up were accessed. Results: Sixteen surgeries were done (15 patients). The patient's mean age was 35 years (28- 43); ten women were nulliparous of which nine were infertile. Dysmenorrhea was the most frequent symptom (n=12), followed by dyspareunia (n=8). In six women a node in the rectovaginal septum was present in the physical exam. In six cases a colpectomy was done in order to accomplish total excision of the rectovaginal node. One discoid excision of the rectum was done. No conversions to laparotomy were needed. The mean operative time was 142±55min, with estimated blood loss < 250ml in 15 surgeries. There was a case of an intra-abdominal abscess. Mean follow-up duration was eight months, with 81% of the patients referring clinical improvement. Conclusions: Laparoscopic surgery in the treatment of deep endometriosis requires a high degree of surgical expertise and the approach by a multidisciplinary team. Only then, a low rate of complications, symptoms regression and a potential fertility improvement can be achieved.

Complicações da sacropexia laparoscópica: serão assim tão inofensivas?

Overview and aims: To analyze all patients needing surgical treatment for complications related to laparoscopic sacropexy and their clinical management. Study Design: Case series. Population: All women submitted to surgical treatment of complications related to laparoscopic sacropexy for pelvic organ prolapse treatment on a tertiary referral center (university hospital), from January 1998 to December 2013. Methods: Retrospective analysis of the patients' clinical records. Results: Thirty-three patients were submitted to surgery due to complications related to the procedure, some more than once, with more than one complication registered. There were 6 general surgical complications (2 hematomas, 2 peritonitis, 1 mechanical bowel obstruction due to small bowel incarceration and 1 vaginal wall necrosis) and 34 mesh related complications (27 vaginal mesh exposures, 4 periprosthetic abscesses, 1 vesicovaginal fistula, 1 rectovaginal fistula and 1 posterior mesh retraction). Mean time between prolapse surgery and the first surgery for complication treatment was 18.2 ± 25.3 months (3 days - 131 months). The average number of surgeries needed was 1.8 ± 1.5(1- 6). Conclusions: Surgeons should be aware of the risk factors for complications. Longterm complications should not be neglected. After a mesh placement, patients are at risk for requiring multiple surgeries to resolve complications, which can be challenging, ineffective and expose patient to new ones.

Apoptose e proliferação celular na endometriose: estado da arte

Endometriosis is a disease characterized by the ectopy of endometrial glands and stroma, which can significantly compromise the quality of life in childbearing-age women. Its etiology remains uncertain since retrograde menstruation does not completely explain the endometriosis implant fixation process. Apoptosis and cellular proliferation, fundamental processes to endometrial tissue homeostasis, present changes in the endometrium of women who suffer from this disease, which may help to explain its pathogenesis. Hormonal treatment usually controls symptoms associated with this disease. Its effects include the interference with the regulation of apoptosis and cellular proliferation. The objective of this review is to highlight the main subcellular environment changes in endometriosis, referring to the factors that regulate apoptosis and cellular proliferation, and how all those factors evolve with the hormonal treatment.

A utilização da metformina durante a gravidez

Metformin is an effective oral anti-diabetic that has been used in pregnancy during the last decades. However, metformin crosses the placenta, so its use remains controversial. Scientific evidence suggests that the use of metformin in pregnancy is safe. In the treatment of gestational diabetes has efficacy comparable to insulin, and in polycystic ovary syndrome improves pregnancy success rate, prevents ovarian hyperstimulation syndrome and might reduce some pregnancy complications. Although there is no evidence of modifications in the development of children exposed to metformin, more studies are needed to evaluate the long-term effects.

Um novo modelo de carcinogénese para cancro do ovário: implicações clínicas da salpingectomia profiláctica

Ovarian cancer is the most lethal gynaecological malignancy. There is limited knowledge regarding this cancer and we are witnessing a paradigm shift, in which the Fallopian tube is considered the primary site of most high-grade serous carcinoma (HGSC). The aim of this article is to review the current body of knowledge of the origin and pathogenesis of ovarian cancer and the clinical implications of the new model of carcinogenesis. During more than 30 years, the prevailing view on the origin of HGSC was that it derived from the ovary, since the ovarian surface epithelium is exposed to inflammation and oxidative stress induced by ovulation. The incessant ovulation hypothesis was proposed by Fathalla in 1971. At the beginning of this century, many studies were published demonstrating the presence of invasive and non-invasive carcinoma in the fallopian tubes of prophylactic salpingo-oophorectomies performed in carriers of BRCA mutation, which led some authors to suggest the fallopian tube as the origin of these tumors. This theory was published in 2007, by Kindelberger, who described the precursor lesion - serous tubal intraepithelial carcinoma (STIC). The advances in cellular and molecular biology and in genetics added support for this new concept, indicating that the HGSC develops from an occult intraephitelial carcinoma in the fimbria of the fallopian tube and involves the ovary secondarily. Observational epidemiologic evidence strongly supports that tubal ligation and hysterectomy are associated with a decrease in the risk of ovarian cancer, by approximately 26-34%. The additional bilateral salpingectomy to hysterectomy does not affect ovarian function, and has no significant differences in rate of complications and operative time. Considering the new insights into the origin of HGSC, in which the majority is of tubal origin, there is a significant preventive potential by performing prophylactic salpingectomy.

Cancro do ovário na adolescência: um caso clínico

Small cell carcinoma of the ovary, hypercalcemic type is a rare and aggressive tumor affecting young women. The mechanism of development is unclear and there have been relatively few clinical studies reported in literature. The authors present a clinical case of a 15-year-old girl with a small cell carcinoma of the ovary.

Modulador seletivo dos receptores da progesterona no tratamento de miomas em idade reprodutiva: a propósito de um caso clínico

Fibromyomas are a benign and common condition, with an unclear impact on reproduction. Medical therapy has been the first-line treatment in young women, especially those with previous myomectomy, due to the highest surgical risks, and its adverse effects on fertility. Ulipristal acetate(UPA) appears to be an effective treatment with prolonged effect on symptom control and reduction of myomas. With a wellestablished pre-surgical recommendation, its indication in infertility or prior to a spontaneous pregnancy still has little evidence. The increasing reports of successful pregnancies after treatment with UPA, support its potential usefulness, as seen in the clinical case described.

Implantes de endometriose após cesariana: mais do que uma cicatriz - caso clinico

Introduction: Scar endometriosis after a cesarean section is characterized by the presence of endometrial glands implants at the incision site. It is an uncommon presentation of endometriosis. The diagnosis may be difficult, since it is based in non-specific symptoms, and it can be confused with other surgical conditions. Case Report: The authors report a case of a 35-year-old woman with a cyclic painful nodule at the left side of a cesarean section scar and no previous history of endometriosis. Conclusion: Management and preventive measures of this entity are discussed.

Gravidez na Síndrome de Marfan: dois casos clínicos

Marfan syndrome is a connective tissue disorder, autosomal dominant, which affects multiple organ systems, namely the cardiovascular, ocular and skeletal. Morbidity and mortality result primarily from aortic and cardiac complications including dilatation, dissection and rupture of the aorta. As a result, pregnancy in women with the Marfan syndrome has an increased risk. Main causes of complications are related with hemodynamic and hormonal modifications caused by pregnancy. The approach to pregnancy in patients with this syndrome is challenging and deserves special care. A multidisciplinary surveillance plan should be developed with support from cardiology, maternal fetal medicine, anesthesiology, genetics and pediatrics.