Acta Obstétrica e Ginecológica Portuguesa

Ethnicity/racial impact in gestational diabetes mellitus

Overview and Aims: Gestational diabetes (GD) is associated with increased risk for pregnancy and delivery complications. Ethnicity is a recognized risk factor for GD. Considering ethnic diversity in Portugal, it is important that health providers are familiar with differences in expected outcomes. This study was designed to compare Asian, Black and Caucasian women with GD. Study Design: Observational, retrospective study. Population: Women with singleton pregnancies and GD followed in our hospital, from 2012 to 2015. Materials and Methods: 323 women were divided according to country of birth and skin color - Caucasian (G1, n=230), Black (G2, n=79) and Asian (G3, n=14). Demographic characteristics, risk factors for GD and previous hypertension were compared. Maternal/fetal outcomes were analyzed - maternal weight gain, metabolic control, need of pharmacologic therapy, hypertensive complications, ultrasound biometric measures, intrauterine demise, mode of delivery, newborn weight and comorbidities. X2 and Fisher tests were performed. Significance was set at p-value<0.05. Results: G1 included women mainly from Portugal, G2 from Guinea Bissau, Angola and Portugal and G3 from India. Groups differed in level of education (p=0.023) and Body Mass Index categories (p=0.034) - G2 had the lowest level of education and the highest rates of overweight/obesity. Statistical difference was found in metabolic control, resulting in glycated haemoglobin below 6% (p=0.022) and mode of delivery (p<0,001); G2 and G3 had worse metabolic control than G1, with higher C-section rates. Neonatal comorbidity differed between groups (p=0.021), with G2 having higher rates, mainly hyperbilirrubinemia requiring phototherapy. Need or type of pharmacologic therapy (insulin/metformin) showed no difference between groups. Conclusions: Metabolic control in Asian and Black women with GD was more difficult to achieve than in Caucasians, with afterwards worse maternal/fetal outcomes. Health providers should acknowledge differences between ethnicities and a multidisciplinary and individualized approach should be provided.

sFlt-1/PlGF ratio for the predictive diagnosis of preeclampsia: budget impact analysis from the public healthcare perspective in Portugal

Overview and Aims: The last decade brought relevant insights into the pathophysiology of preeclampsia (PE), namely the role of the circulating levels of placental growth factor (PlGF) and soluble Fms-like tyrosine kinase-1 (sFlt-1). The purpose of this study is to estimate the financial impact of introducing the sFlt-1/PlGF ratio for the evaluation of women with suspicion of PE in the Portuguese National Healthcare System (SNS). Study Design: budget impact study evaluating short-term costs associated with the introduction of the sFlt-1/PlGF ratio from the SNS payer's perspective. The time horizon for the study is 1 year. Population: The target population consists of women presenting to the healthcare system with signs or symptoms suggestive of preeclampsia (estimated in 8500 subjects). Methods: A decision-tree model was used to estimate the budget impact of the introduction of the sFlt-1/PlGF ratio in the SNS. The model compares the management costs in the current clinical practice (no test scenario) vs. current diagnostic procedures plus the sFlt-1/PlGF ratio (test scenario). Clinical inputs have been derived primarily from literature review and, where data was unavailable, expert opinion. Resources and unit costs have been obtained from Portugal-specific sources. Results: In the current standard practice (no test), total costs were estimated to be e9 863 264 (e1160 per patient), with unnecessary admissions representing about e3,5 million. Total costs in the test scenario sum up to e9 781 194 (e1150 per patient), representing a cost saving to the system of e82 070 (e10 per patient), mainly due to a reduction of false positives and related unnecessary hospitalizations of women not developing PE. Conclusions: There is favorable economic evidence about the introduction of the sFlt- 1/PlGF ratio in the SNS. The generated savings appear to offset the costs related to the test.

Why do our patients complain?The casuistry of a Gynaecology and Obstetrics Department

Overview and Aims: Patient satisfaction when using health services is an indicator often used for quality measurement. This study aims to analyze the complaints to assess the reasons for displeasure in the care provided as a way to recognize patients as active agents in the improvement of health services. Study design, Population, Methods: An observational, descriptive, retrospective study was performed through the acquisition of complaints made by the users of the service in the patient's office of the Hospital Center between 2008-2016. The data obtained were analyzed qualitatively and quantitatively. Results: A total of 91 complaints were identified in the nine years of the study, corresponding to an average complaint rate of 0.2. The propensity to complain was similar over time, with predominance of complaints in their own name and concerning the area of obstetrics (compared to gynaecology). Complaints addressed to health professionals refer, mainly, to doctors or medical acts. The prevalent typology of complaints refers to the domain of relationships predominantly in communication, followed by those related to institutional management. The situations of the clinical domain that encompass the quality and safety of the care provided was a reason for complaint in 27% of the situations. Conclusions: From the analysis of the complaints we believe that these are predictive of deficiencies found later, so that they offer a signal in real time of a service quality. In situations of frustration of users' expectations, it seems to be important to bet on the best information regarding rights and duties in health care.

Preeclampsia in twin pregnancy

Twin pregnancy is a high-risk condition and its incidence has raised over the last decades. Hypertensive disorders are among the most common medical complications of pregnancy. While is unquestionable that multiple pregnancy has an increased risk of preeclampsia (PE), it's unclear what are the other risk factors. The pathophysiology of PE is uncertain but is thought to be a condition of poor placentation, resulting in generalized vascular endothelial activation and vasospasm. Published data also show that an angiogenic/anti-angiogenic balance plays a causative role in endothelial cell injury. Increasing the knowledge about PE in twin gestation may improve patient's surveillance.

Uterine morcellation: Update and proposal of an informed consent

Morcellation is a surgical technique, sometimes necessary to perform minimally invasive surgery, namely laparoscopic hysterectomy and myomectomy. As it is difficult to distinguish preoperatively a fibroid from a leyomiosarcoma, there are concerns that inadvert morcellation of a malignant tumor might occur, in which case the prognosis of the disease might be worsened. As new evidence arises regarding patient selection, preoperative care and preventive measures, it has become mandatory to inform and discuss the risks and benefits of the procedure with the patient, so that a true informed consent is achieved.

Meigs Syndrome with elevated CA 125: case report

Meigs syndrome is a rare medical entity. It is defined by a triad of a benign ovarian tumor, ascites and pleural effusion that resolves after tumor resection. This syndrome in known since the 19th century, but its pathophysiology it stills unclear. It has a progressive incidence from the third decade of life until the menopausal age. Its clinical importance relays on the fact that it is a benign condition with an excellent prognosis, contrary to other ovarian malignancy with peritoneal and pleural metastasis. The present article aims to report a clinical case of Meigs syndrome.

Crown-rump length discordance in dichorionic twins in the first trimester: different obstetric outcomes

First trimester intertwin crown-rump length (CRL) discordance has been suggested to predict adverse perinatal outcomes. In dichorionic diamniotic pregnancies its etiology is poorly understood. We report the cases of two sets of dichorionic twins with crown-rump length discordance diagnosed in the first trimester of pregnancy with different obstetric outcomes. In the first case, no specific cause to justify the discordant growth was found, with the pregnancy ending in a preterm birth due to severe intrauterine growth restriction of fetus 2. The second case was associated with triploidia of the smallest fetus, with normal development and birth of the co-twin. The role of first trimester ultrasound in predicting an adverse perinatal outcome is still controversial and the optimal management of twin pregnancies with CRL discordance is a challenging question.

Primary fetal pleural effusion: a case of successful prenatal intervention

Fetal pleural effusion is a rare condition whose prognosis is highly variable. Most primary cases are chylothorax and prenatal interventions can significantly alter its natural course. Some authors defend thoracoamniotic shunting as the preferred intervention but in few cases the effusion may resolve or stabilize after a single transabdominal thoracentesis. The authors present a case of primary bilateral pleural effusion identified at the 31st gestational week. A thoracentesis was performed at the 32nd week. A little effusion was maintained, with no reaccumulation. The newborn had an appropriate respiratory response at delivery and no thoracentesis was required in the neonatal period.

One plus one equals three!! Penis duplication in a multiple pregnancy: Duplicação peniana numa gravidez múltipla

Diphallia is a rare condition and can be diagnosed antenatally. In this case, a cyst adjacent to the penis of fetus 1 was detected at the second trimester ultrasound. He was born with diphallia with sagittal duplication (the dorsal glans was smaller than the ventral glans). Both phalluses had distinct and independent urethral meatuses and there were no hypospadias. The prognosis depends on whether it is associated or not with other congenital malformations.

Anemia in pregnancy and postpartum