Acta Obstétrica e Ginecológica Portuguesa

70 anos da Declaração Universal dos Direitos Humanos: o futuro na saúde e direitos sexuais e reprodutivos

"Quando vi as barbas do meu vizinho a arder..."

The high maternal mortality rate in the United States has worried health care providers. Portugal has a lower maternal mortality rate but with the finantial constraints of the National Health Service can face the same problem in the future

Avaliação da experiência das pacientes na histeroscopia de consultório versus ambulatório

Overview and Aims: Technology has allowed hysteroscopy to be increasingly performed in the office (HO). Yet, fear of patient pain associated with HO still prevents clinicians from choosing it instead of traditional hysteroscopy (HA). We aimed to compare pain perception and satisfaction in patients submitted to HO versus HA and to determine socio-demographic and clinical factors that influence patient experience. Methods: We performed a prospective, observational, descriptive and analytical study, comparing women submitted to HA (n=119) and HO (n=113), between September and December 2016 and January to July 2017, respectively. Three self-report questionnaires were answered by the patients before, immediately and one month after the hysteroscopy, and another questionnaire was answered by the clinician in charge of the technique. Results: Both HA and HO groups showed similar socio-demographic characteristics. Differences were found between felt and expected pain, both in HA (p<0,001) and HO (p= 0,001), with expected pain being higher in both groups. Despite HO group reported higher levels of pain (visual analog scale 4 versus 1,87 in the HA group), patients in this group presented significantly higher satisfaction regarding information given before (p=0,040) and after procedure (p<0,001) and with changes in their daily life (p<0,001). Generally, HO group showed higher levels of global satisfaction concerning the procedure (mean 20,45 versus mean 19,4 in the HA group, p= 0,001). Furthermore, the waiting time until hysteroscopy was lower in the HO group (p=0,007). We found no association between patients characteristics and the level of global satisfaction and experienced pain during hysteroscopy. Conclusion: HO presents higher levels of global satisfaction, which may be related to better communication, less waiting time until procedure and faster return to daily activities. Thus, given the safety and cost-effectiveness of HO, fear of patient pain should not prevent most diagnostic and simple surgical hysteroscopies from being performed in the HO context.

Essure®: efetividade, complicações e satisfação em 13 anos de experiência

Overview and aims: Female sterilization is the most used contraceptive method in the world. The hysteroscopic route is especially attractive for women at high surgical and anesthetic risk. Publications worldwide reported several possible adverse events, doubting the safety of the method. The objectives of this study are to evaluate the technical difficulties and complications, the adverse events in the short and long term, the effectiveness of the method and satisfaction. Study design: Retrospective cohort study. Population: A total of 105 women undergoing hysteroscopic sterilization with Essure® between 2005 and 2017 (13 years of study). Methods: The epidemiological and procedural data were accessed by consulting the clinical processes the family planning appointments. Long term follow-up was evaluated by telephone contact of all the women, with success in 68 cases. Results: The mean age was 38 years (SD 4,7). The procedure was successful in the first attempt in 99% (n=67) cases, the main technical difficulty identified was the permeabilization of the internal cervical os (8.6%; n=6) and the only intercurrence documented was vasovagal reaction (4.8%; n=3). The mean immediate pain post procedure was 4 (numeric pains cale, SD 2). Long term complications identified were: 1.5% (n=1) migration, 1.5% (n=1) partial unilateral expulsion, 4.4% (n=3) gynecological reoperation, 9% (n=7) headache, 11.8% (n=8) weight gain, 22.1% (n=15) chronic pelvic pain and 24.6% (n=17) abnormal uterine hemorrhage. There were no cases of pregnancy or allergic reaction. Most women were very or completely satisfied and would advise Essure® as a contraceptive method, 94% (n=64) and 97.1% (n=66) respectively. Conclusions: Hysteroscopic sterilization was highly effective and associated with low and mild difficulties and acute complications. Most women were satisfied with the method and long term adverse effects identified are difficult to promptly associate with Essure® since their high frequency in the peri-menopause, forcing more studies.

Bacteriúria e patologia do pavimento pélvico

Overview and Aims: Pelvic floor dysfunction is associated with an increased risk of urinary tract infection (UTI). The correction surgery is a risk for UTI. The first objective was to evaluate and compare bacteriuria rates in patients with pathology of the pelvic floor (pelvic organ prolapse (POP) and/or urinary incontinence (UI)). The second objective was to evaluate bacteriuria rate after surgery. Study Design, Population and Methods: retrospective study that included women proposed for surgery for POP and/or stress urinary incontinence (SUI) between January 2009 and May 2015, in a tertiary hospital. The patients who collected urine for urine culture (UC) before and after intervention were included. Results: For assessment of the first objective 373 patients were included and divided into three groups: POP (168), SUI (117) and POP + SUI (88). The overall bacteriuria rate before surgery was 13.7% (51/373), with no statistically significant difference between the groups: POP (13,1%) vs IU (13,7%) vs POP+IU (14,8%) (p=0,933). To evaluate the second objective 228 patients undergoing surgical correction were included: POP (113) SUI (44) and POP and SUI (71). The overall bacteriuria rate in the postoperative period was 9.6% (22/228), with no statistically significant difference between the groups: POP (9,7%) vs SUI (13,6%) vs POP+SUI (7,0%) (p=0,507). Conclusions: Global bacteriuria rates found are consistent with previous studies. There was no significant variation between bacteriuria rate and surgical intervention performed, namely to correct POP and/or SUI. For this sample, bacteriuria rate in patients with pathology of the pelvic floor (POP and/or SUI) does not vary with the identified condition or with the type of surgical correction.

Nicho uterino: implicações em ginecologia

The uterine niche presents as a recess located in the anterior uterine wall, at the site of previous hysterorrhaphy. Although obstetric complications associated with a history of cesarean delivery are well known, recognition of the niche as a surgical sequel and its association with gynecological symptoms such as abnormal uterine bleeding and pelvic pain is poorly described, compromising its identification in clinical practice. There are no validated guidelines for the diagnostic criteria of uterine niche. Treatment includes hormonal methods and surgery, namely hysteroscopic or laparoscopic isthmoplasty.

Terapêutica hormonal após tratamento do cancro do ovário: sim ou não?

The mean age of diagnosis of ovarian epithelial tumors is 63 years, but 3-17% affects women under the age of 40 years. In this age group, standard treatment conditions an iatrogenic menopause, so that conservative therapeutic options are increasingly weighted at early ages. Estrogen therapy is the most effective treatment for the symptoms associated with menopause, but doubts about its use in these women are frequent. The review of the literature shows that after treatment of ovarian cancer, the use of hormone therapy does not influence relapse rates nor overall survival.

McArdle Disease and Pregnancy

McArdle disease is a hereditary skeletal muscle disorder caused by myophosphorylase deficiency. This syndrome is characterized by exercise intolerance, fatigue, myalgias, cramps, and weakness. It is a rare disease, with few reported cases of pregnancy in women with this condition. Despite not having specific treatment, adequate physical activity can improve patient symptoms and prevent acute rhabdomyolysis. We present a case of a pregnant woman with McArdle disease. During pregnancy there was an improvement of exercise tolerance and creatine kinase levels. This case report illustrates our experience regarding the management of pregnancy and labour in women with McArdle disease.

Gravidez após carcinoma do endométrio: caso clínico e revisão da literatura

Although endometrial cancer is primarily a postmenopausal disease, around 4 percent of patients are younger than 40 years and may desire fertility, requiring conservative treatment options. We describe a clinical case of a 34-year-old nulligesta diagnosed with early stage endometrial carcinoma who achieved a term pregnancy with live birth after conservative fertility sparing treatment with progestins. At two-year follow up, after childbearing and still preserving fertility, she remains in complete remission of the disease. An insight on conservative approaches is provided and potential risks are discussed.

Tunnel cluster cervical de grandes dimensões

Nabothian cysts are retention cysts of the uterine cervix, which rarely may appear as multilocular large lesions called tunnel cluster. The authors report a case of a complex pelvic mass with 53x43 mm incidentally detected during a CT exam, initially interpreted as an adnexal mass. At ultrasound there was a big cystic tunnel cluster (type B) of the cervix, with more than 12 loci, the largest with 26 mm, with no vascularisation, occupying the whole cervix, with a multilocular pattern at 3-dimensional ultrasound.

Tratamento da Anemia ferropénica: Recomendações da Sociedade Portuguesa de Ginecologia

Overview and aims: This article addresses the diagnosis of anemia in the context of abnormal uterine bleeding and reviews the treatment options of iron deficiency anemia. This topic was worked out as a section of the Portuguese Consensus on Abnormal Uterine Bleeding, endorsed by the Portuguese Society of Gynaecology. The working group established recommendations that provide guidance to the medical society to better decision making concerning the treatment of iron deficiency anemia. We expose here evidence based guidelines consigning the diagnosis and management of this disease. Study design and Methods: A group of experts in the field performed a thorough systematic search of the publications on the treatment of iron deficiency anemia and a quality assessment of the included papers. On this basis a proposal was drawn up and later on was discussed and approved on consensus meeting with all members of the guidelines developing group reaching the final version of the recommendations. Conclusions: The present clinical practice guidelines on treatment of iron deficiency anemia may improve the diagnosis and management of this high prevalent disease.