Development and internal validation of a clinical score to predict neonatal hypoglycaemia in women with gestational diabetes.

INTRODUCTION: Gestational diabetes (GD) is a risk factor for neonatal hypoglycaemia (NH), but other factors can increase this risk. OBJECTIVES: To create a score to predict NH in women with GD. METHODS: Retrospective study of women with GD with a live singleton birth between 2012 and 2017 from the Portuguese GD registry. Pregnancies with and without NH were compared. A logistic regression was used to study NH predictors. Variables independently associated with NH were used to score derivation. The model's internal validation was performed by a bootstrapping. The association between the score and NH was assessed by logistic regression. RESULTS: We studied 10216 pregnancies, 410 (4.0%) with NH. The model's AUC was 0.628 (95%CI: 0.599-0.657). Optimism-corrected c-index: 0.626. Points were assigned to variables associated with NH in proportion to the model's lowest regression coefficient: insulin-treatment 1, preeclampsia 3, preterm delivery 2, male sex 1, and small-for-gestational-age 2, or large-for-gestational-age 3. NH prevalence by score category 0-1, 2, 3, 4, and ≥5 was 2.3%, 3.0%, 4.5%, 6.0%, 7.4%, and 11.5%, respectively. Per point, the OR for NH was 1.35 (95% CI: 1.27-1.42). A score of 2, 3, 4, 5 or ≥6 (versus ≤1) had a OR for NH of 1.67 (1.29-2.15), 2.24 (1.65-3.04), 2.83 (2.02-3.98), 3.08 (1.83-5.16), and 6.84 (4.34-10.77), respectively. CONCLUSION: Per each score point, women with GD had 35% higher risk of NH. Those with ≥6 points had 6.8-fold higher risk of NH compared to a score ≤1. Our score may be useful for identifying women at a higher risk of NH.

Severe primary hypothyroidism and ovarian hyperstimulation syndrome in a spontaneous pregnancy: a case report.

Background: Ovarian hyperstimulation syndrome (OHSS) is a rare ovulation induction therapy side effect. Nevertheless, it can occur in spontaneous ovulation cycles linked to multiple gestation, molar pregnancy, polycystic ovarian syndrome, and hypothyroidism. The pathogenesis of OHSS remains poorly understood. However, in recent studies, it has been observed that increased concentrations of thyroid-stimulating hormone (TSH) can potentially have stimulatory effects on the ovaries due to the homologous structure shared between TSH and gonadotropins. It is recommended to delay pregnancies until euthyroidism is achieved with replacement therapy to reduce potentially fatal problems. Case Description: We describe the case of a 22-year-old female patient who sought medical attention due to a 4-week history of abdominal discomfort and amenorrhea. Upon evaluation, it was determined that she was in the 9th week of pregnancy and experiencing OHSS due to severe primary hypothyroidism. The diagnosis was confirmed through laboratory and imaging data, enabling timely care and preventing complications arising from unwarranted surgical intervention. Administration of levothyroxine led to total regression of the ovarian cysts. Even so, the patient decided to terminate her pregnancy. Conclusions: This case illustrates the occurrence of OHSS in a woman with untreated hypothyroidism. Notably, this syndrome is relatively uncommon, and the patient's ability to conceive while having unviable thyroid hormone levels further adds to this case's exceptional nature.

Impact of pharmacological treatment of gestational diabetes on the mode of delivery and birth weight: a nationwide population-based study on a subset of singleton pregnant Portuguese women.

AIMS: To access the impact of increasing use of metformin on cesarean section and large for gestational age rates, when compared to insulin. METHODS: A retrospective observational study was developed using data from the Portuguese National Registry, between 2011 and 2019, of 5038 Portuguese women with single pregnancies and gestational diabetes treated with metformin and/or insulin. Three groups were defined according to the therapeutic regimen adopted: g1-insulin in monotherapy (n = 3027[60.1%]); g2-metformin in monotherapy (n = 1366[27.1%]); g3-metformin and insulin (n = 645[12.8%]). Multivariate analysis was adjusted for statistically significant covariates. RESULTS: The cesarean section rate in g1 was similar to g2 (g1:36.9% vs. g2:37%, p = 0.982), although g3 was associated with cesarean delivery (g3:43.6% vs. g1:36.9%, p = 0.005; g3:43.6% vs. g1:37.0%, p = 0.002), with no differences reported in the multivariate analysis adjusted for year of delivery and pregestational body mass index. A delivery of a large for gestational age newborn was less frequently observed in g2 than in g1 (g2:4.1% vs. g1:5.4%, p = 0.044) and in g3 (g2:4.1% vs. g3:9.1%, p < 0.001), and in g1, when compared to g3 (g1:5.4% vs. g3:9.1%, p < 0.001). In the multivariate analysis, g2 showed lower odds of delivering a large for gestational age newborn, compared to g1 (ß = -0.511, OR = 0.596, CI95% = 0.428-0.832, p < 0.001). CONCLUSIONS: The use of metformin was not associated with higher cesarean section rates, compared to insulin. Instead, it was suggested a protective role of metformin on large gestational age rates. The concomitant use of dual therapy suggests more complex pregnancies, requiring closer surveillance that mitigate serious perinatal and obstetrical outcomes.

[Demographic and Professional Characteristics of Specialists in Obstetrics and Gynecology Registered in Portugal: Needs, Resources and Challenges]. / Características Demográficas e Profissionais dos Especialistas em Ginecologia-Obstetrícia Registados em Portugal: Necessidades, Recursos e Desafios.

INTRODUCTION: The demographic and professional characteristics of specialists in Obstetrics and Gynecology registered in Portugal are presented and current and future needs assessed. MATERIAL AND METHODS: An analysis of the data from Instituto Nacional de Estatística, Ordem dos Médicos and a survey sent to the directors of the departments of Obstetrics and Gynecology of Portuguese hospitals was perfomed. In order to calculate the necessary number of specialists, established indicators of the activity of the specialty were used. RESULTS: In 2018, there were 1 437 441 consultations of Obstetrics and Gynecology, 89 110 major gynecologic surgeries and 85 604 deliveries. For that, 1065 Obstetrics and Gynecology physicians, working 40 hours per week, with no more than 40% aged 55 years of age and older or including 30 residents per year, are deemed necessary. According to the National Institute of Statistics, in the same year there were 1143 specialists in Portuguese hospitals, of which 234 worked in private hospitals. On the other hand, 1772 specialists were registered with the Ordem dos Médicos: 1163 (66%) were aged 55 years old or above and 84% of specialists under the age of 40 were females. In 2020, there were 864 specialists, 46% of which aged years of age and older working in 39 out of the 41 public or public-private departments that answered the survey. In 2035, an increase of 7% in the required number of specialists is expected. CONCLUSION: In Portugal, there is not lack of Obstetrics and Gynecology specialists in absolute numbers, but the large number of specialists aged 55 years of age and older, who are exempt from shifts in emergency department work, and the existence of regional asymmetries contribute to the perpetuation of some shortages of these healthcare professionals in several departments, namely in public hospitals.

Introdução: Apresentam-se as caraterísticas demográficas e profissionais dos especialistas de Ginecologia-Obstetrícia registados em Portugal e avaliam-se necessidades atuais e futuras.Material e Métodos: Analisaram-se dados do Instituto Nacional de Estatística, da Ordem dos Médicos e de resposta a questionário enviado a diretores de serviços hospitalares portugueses de Ginecologia-Obstetrícia. Calcularam-se as necessidades de especialistas com base em indicadores estabelecidos de atividade médica da especialidade.Resultados: Em 2018, registaram-se, em Portugal, 1 437 441 consultas da especialidade, 89 110 grandes cirurgias e 85 604 partos. Para essa atividade calcula-se serem necessários 1065 médicos da especialidade, em regime de 40 horas semanais, dos quais não mais do que 40% com idade igual ou superior a 55 anos; para manter este número são necessários 30 internos por ano. Segundo o Instituto Nacional de Estatística, nesse ano existiam 1143 especialistas nos hospitais portugueses, 234 dos quais em hospitais privados. Por outro lado, estavam inscritos 1772 especialistas na Ordem dos Médicos, dos quais 1163 (66%) apresentavam uma idade igual ou superior a 55 anos, sendo 84% dos especialistas com menos de 40 anos do sexo feminino. Em 2020, nos 39 dos 41 serviços públicos e público-privados que responderam ao questionário, existiam 864 especialistas, dos quais 395 (46%) com idade igual ou superior a 55 anos. Para 2035 prevê-se um aumento de 7% nas necessidades de especialistas desta área.Conclusão: Em Portugal não há falta de especialistas de Ginecologia-Obstetrícia em número absoluto, mas a existência de um elevado número de especialistas com idade igual ou superior a 55 anos, que tem direito a deixar de prestar atividade nos Serviços de Urgência, e de assimetrias regionais, contribuem para que continuem a existir algumas carências destes profissionais em vários serviços, nomeadamente em hospitais públicos.

Knowledge and Patterns of Use of Emergency Oral Contraception among Portuguese Female Users of Healthcare Services.

INTRODUCTION: The lack of knowledge about the existence, effectiveness, and supply of emergency contraception as well as access to it, its effective duration and the lack of recognition of the need for its use can prevent women from using it. The aim of this study was to ascertain the attitudes, experience, level of knowledge and information sources about emergency contraception of Portuguese female users of healthcare services. MATERIAL AND METHODS: We conducted a multicentre, cross-sectional, observational study among 280 Portuguese women users of health care services through an original and anonymous questionnaire composed of 30 questions. RESULTS: The mean age of the women who replied to the questionnaire was 33.83 ± 8.76 years. Of the observed sample, 27.7% used EC, 50% of whom with no counselling. Despite 92.1% of women claiming knowledge about emergency contraception, only 31.2% of these answered 8 - 10 questions correctly (14 in total). The media were the most frequent source of information (63.4%). Most participants (67.5%) considered that emergency contraception is associated with severe adverse reactions. Furthermore, 76% did not know the time range of effectiveness after unprotected sexual intercourse. Youngest age (p = 0.038), higher education level (p < 0.001), increasing parity (p = 0.051) and previous use of emergency contraception (p = 0.011) were identified as the determinant sociodemographic factors for a higher level of knowledge about emergency contraception. DISCUSSION: The use of emergency contraception after counselling by healthcare professionals was lower than reported in the literature. CONCLUSION: This study showed that female users of healthcare services were aware of the existence of emergency contraception, but they demonstrated a low level of knowledge about it, especially regarding the correct period of use, place of acquisition and safety issues.

Introdução: A falta de conhecimento sobre a existência, eficácia e fornecimento da contraceção de emergência, bem como a sua acessibilidade, prazo efetivo e a falta de reconhecimento da possibilidade da sua utilização podem impedir as mulheres de a utilizarem. O objetivo do estudo foi conhecer a experiência, atitudes, as fontes de informação e nível de conhecimento sobre a contraceção de emergência entre mulheres portuguesas utilizadoras dos cuidados de saúde. Material e Métodos: Foi desenvolvido um estudo observacional, transversal e multicêntrico em 280 mulheres portuguesas utilizadoras dos cuidados de saúde, através da aplicação de um questionário original e anónimo constituido por 30 questões. Resultados: A idade média das mulheres que responderam ao questionário situou-se nos 33,83 ± 8,76 anos. Da amostra em estudo, 27,7% referiram utilização prévia de contraceção de emergência, das quais 50% sem aconselhamento. Apesar de 92,1% afirmar conhecer esta opção, apenas 35,9% respondeu corretamente a entre oito a 10 questões de avaliação de conhecimento (total de 14). Os media constituiram a fonte de informação mais frequente (63,4%). A maioria das participantes (67,5%) considera que a contraceção de emergência está associada a efeitos adversos graves e 76% desconhece o intervalo de tempo de eficácia da contraceção de emergência após relações sexuais desprotegidas. A idade jovem (p = 0,038), maior nível de escolaridade (p < 0,001), o aumento da paridade (p = 0,051) e a utilização prévia de contraceção de emergência (p = 0,031) foram os fatores sociodemográficos associados a maior nível de conhecimento sobre a mesma. Discussão: O uso de contraceção de emergência após aconselhamento por profissionais de saúde foi inferior ao descrito na literatura. Conclusão: O estudo demonstrou que apesar das utilizadoras dos cuidados de saúde de afirmarem ter conhecimento da existência da contraceção de emergência, revelaram baixo nível de conhecimento sobre este tipo de contraceção, particularmente em relação ao período correto de utilização, local de aquisição e questões de segurança.

[Opportunistic Salpingectomy for Permanent Contraception: A Cross Sectional Study in Portugal]. / Salpingectomia Profilática como Método de Contraceção Definitiva: Estudo Transversal em Portugal.

INTRODUCTION: Opportunistic bilateral salpingectomy has been proposed as an ovarian cancer risk-reducing strategy namely as a means of tubal sterilization. We aimed to assess what were the procedures for interval and peripartum sterilization carried out nationwide, related motivational aspects and influential demographic or professional factors. MATERIAL AND METHODS: Cross-sectional study based on an original survey sent to Obstetrics and Gynecology specialists and residents from across the country in 2019. RESULTS: Two hundred and twenty-five answers were obtained from 42 institutions (37 from the public sector). Laparoscopic tubal electrocoagulation (61%) was the most common procedure for interval sterilization followed by salpingectomy (28%). Major reasons pointed out for not performing salpingectomy were increased operative time (48.5%) and procedure not considered (45.5%). In some hospitals, the choice of salpingectomy depended on specific criteria namely surgical team decision. During cesarean-section, sterilization was most frequently performed using the modified Pomeroy technique (54%), followed by salpingectomy (32.5%), with a statistically significant prevalence in the north of the country. Sixty-nine percent of Portuguese Obstetrics and Gynecology residents and specialists consider that salpingectomy should be the procedure offered to women asking for definitive contraception. DISCUSSION: Although data are limited, salpingectomy at the time of cesarean delivery appears feasible and safe and this context might represent the best opportunity for intervention. CONCLUSION: Opportunistic salpingectomy is not the most common sterilization procedure performed in Portugal, but it was considered the best choice to offer. Its benefits and risks should be discussed with women.

Introdução: A salpingectomia profilática foi proposta como estratégia de redução do risco de cancro do ovário e método de contraceção definitiva. O objetivo deste estudo foi conhecer os procedimentos realizados a nível nacional para contraceção definitiva de intervalo e peri-parto, a opinião e motivações dos clínicos, e os fatores demográficos ou profissionais influentes.Material e Métodos: Este é um estudo analítico transversal, baseado num questionário original enviado durante o ano de 2019 a especialistas e internos de Ginecologia-Obstetrícia a exercer em Portugal.Resultados: Obtivemos 225 respostas provenientes de médicos a exercer em 42 hospitais (37 públicos). A laqueação tubar laparoscópica por eletrocoagulação e corte (61%) foi o método mais frequentemente utilizado na mulher não grávida, seguido da salpingectomia (28%). Os principais motivos apontados para não realizar salpingectomia foram o aumento do tempo operatório (48,5%) e tratar-se de procedimento não equacionado (45,5%). Em alguns hospitais, a realização deste método dependia da decisão da equipa cirúrgica. No contexto per-cesariana, a técnica mais comum foi a de Pomeroy modificada (54%), seguida da salpingectomia (32,5%), com uma concentração no Norte do país com significado estatístico. A maioria (69%) dos participantes consideraram que a salpingectomia deveria ser o procedimento disponibilizado.Discussão: Apesar da evidência científica ainda ser escassa, a salpingectomia per-cesariana parece exequível e segura, podendo representar a melhor oportunidade para intervenção no contexto da contraceção definitiva.Conclusão: A salpingectomia profilática não é o procedimento de esterilização mais comum em Portugal, mas foi considerada como a escolha mais adequada. Os seus benefícios e riscos devem ser discutidos com as mulheres.

Metformin combined with insulin in women with gestational diabetes mellitus: a propensity score-matched study.

AIM: Metformin use in gestational diabetes (GDM) is a common practice. Although its use in combination with insulin might be advantageous, it was never formally tested. We studied whether combined treatment was associated with better obstetric or neonatal outcomes compared to insulin alone. METHODS: This is a retrospective study, using the Portuguese National Registry of GDM (2012-2017), of women treated with insulin ± metformin. Primary endpoints were obstetric and neonatal complications. Secondary endpoints were gestational weight gain (GWG) and insulin dose. A propensity score-matched analysis was performed to balance the distribution of age, BMI, insulin treatment duration, HbA1c, first trimester diagnosis of GDM and previous GDM or macrosomia. Women treated with metformin plus insulin and insulin only were then compared. RESULTS: A total of 4034 women were treated with insulin or insulin plus metformin (10.2%). After propensity score matching, we studied two groups of 386 patients. Obstetric and neonatal complications were similar. Women treated with metformin plus insulin had 201 (52.1%) obstetric complications versus 184 (47.7%) in insulin-only group, p = 0.22; and 112 (29.0%) neonatal complications versus 96 (24.9%), p = 0.19. Patients treated with metformin plus insulin had similar GWG, excessive weight gain and insulin dose compared to the insulin-only group. CONCLUSIONS: Women with GDM treated with insulin plus metformin had similar obstetric and neonatal complications, weight gained and insulin dose compared to those only treated with insulin.

[Short-term neonatal outcomes of vacuum-assisted delivery. A case-control study]. / Complicaciones neonatales a corto plazo de los partos por ventosa. Estudio caso-control.

INTRODUCTION: The purpose of this study was to assess the neonatal morbidity and mortality associated with vacuum-assisted vaginal deliveries compared to all other vaginal deliveries, and to identify the associated risk factors. MATERIAL AND METHODS: We conducted a retrospective case-control study in a level iii maternity hospital between 2012 and 2016, including 1,802 vacuum-assisted vaginal deliveries and 2control groups: 1802 spontaneous deliveries and 909 forceps-assisted deliveries. We considered minor complications (soft tissue trauma, cephalohaematoma, jaundice, intensive phototherapy, transient brachial plexus injury) and major complications (hypoxic-ischaemic encephalopathy, intracranial and subgaleal haemorrhage, seizures, cranial fracture, permanent brachial plexus injury), admission to the neonatal intensive care unit and death. RESULTS: The risk of soft tissue trauma (aOR, 2.4; P<.001), cephalohaematoma (aOR, 5.5; P<.001), jaundice (aOR, 4.4; P<.001), intensive phototherapy (aOR, 2.1; P<.001) and transient brachial plexus injury (aOR; 2.1, P=.006) was higher in vacuum deliveries compared to spontaneous deliveries. Admission to the neonatal intensive care unit was also higher in vacuum deliveries compared to spontaneous deliveries (OR, 1.9; P=.001). When we compared vacuum with forceps deliveries, we found a higher risk of soft tissue trauma (OR, 2.1; P=.004), cephalohaematoma (OR, 2.2, P=.046) and jaundice (OR, 1.4; P=.012). Major complications were more frequent in the vacuum group comparing with the control groups, but the difference was not significant. The 2deaths occurred in vacuum deliveries (1.1 per 1000). CONCLUSION: The proportion of minor neonatal complications was higher in the vacuum-assisted delivery group. Although major complications and death were also more frequent, they were uncommon, with no significant differences compared to the other groups. There are obstetrical indications for vacuum delivery, but it should alert to the need to watch for potential neonatal complications.

Pregnancy in Multiple Sclerosis: A Portuguese cohort study.

BACKGROUND: Pregnancy in Multiple Sclerosis (MS) has been a controversial issue, without international standardized treatment recommendations. The goal of our study was to evaluate the clinical course of MS during pregnancy and the respective therapeutic options, obstetrical outcomes and breastfeeding data. METHODS: This was a retrospective study including women with a diagnosis of relapsing-remitting MS at least one year before pregnancy. Three periods were evaluated: one year prior to pregnancy, pregnancy and one year postpartum. Information acquired included demographic and disease activity data, treatment options, and obstetrical and breastfeeding data. RESULTS: From a cohort of 1134 patients and 777 women, we included 127 pregnancies in 97 women (111 deliveries of a live infant, 11 spontaneous abortions, 3 fetal deaths and 2 voluntary abortions). The annualized relapse rate (ARR) decreased during pregnancy, mainly in the third trimester (prior to pregnancy 0.6 ± 0.8 vs. during pregnancy 0.3 ± 0.6, p = 0.006). There were no significant changes in the ARR in the year after delivery compared to baseline (0.6 ± 0.8 vs. 0.6 ± 0.8, p = 0.895). Patients with relapses in the postpartum period had a shorter disease duration at conception (5.4 ± 3.9 vs. 7.4 ± 4.7; p = 0.029) and breastfed less (53.5% vs. 72.1%, p = 0.046). In the multivariate analysis, relapses during pregnancy predicted postpartum relapses (OR = 4.9, p < 0.005). Neither the previous use of disease modifying therapy (DMT), given to 80.2% of women, nor breastfeeding, caesarean delivery (CD) or epidural analgesia (EA) had an impact on the presence of postpartum relapses. Compared to baseline, the Expanded Disability Status Scale (EDSS) increased in pregnancy and the postpartum period (1.6 ± 0.7 vs. 1.7 ± 0.9 vs. 2.1 ± 1.0, p < 0.001). CD was performed in 43.3% of patients, mainly because of fetal-pelvic incompatibility (35.7%) and EA was performed in 63.9%. The most frequent complications were restriction of fetal growth (4.5%) and gestational diabetes mellitus (3.6%). Concerning newborns, 6.4% had birth asphyxia and 6.1% low birth weight. No malformations were registered. CONCLUSION: Despite a reduction in the relapse rate during pregnancy, the presence of relapses during pregnancy predicted postpartum relapses, with impact on disability. DMT appeared to have no influence on clinical or obstetrical outcome. MS did not have a deleterious effect on the pregnancy course. CD and EA were safe procedures, with a tendency towards CD in MS patients, compared to Portuguese women in general. Breastfeeding did not influence MS activity.

[Chorionicity and adverse perinatal outcome]. / Corionicidade e complicações perinatais.

OBJECTIVE: Considering the highest rate of morbidity and mortality in diamniotic monochorionic twins, the authors evaluated and compared the adverse obstetric and perinatal outcome in twin pregnancies according to chorionicity. PATIENTS AND METHODS: A retrospective study was conducted in all twin deliveries that occurred in the Obstetric Unit of Maternidade Bissaya-Barreto, for a period of tree years (from the 1st of January 1999 until the 31st of December 2001). From de 140 diamniotic twin pregnancies studied, we considered two groups according to the chorionicity: monochorionic and dichorionic. We compared multiple parameters as, epidemiologic data, adverse obstetric outcome, gestacional delivery age, type of delivery and the morbidity, the mortality and the follow-up of the newborn. The statistic tests used were the X2 and the t student. RESULTS: From the 140 twin pregnancies included in the study, 66% (92 cases) presented dichorionic placentation and 34% (48 cases) were monochorionic. In the group of monochorionic pregnancies, we observed highly difference related to pathology of amniotic fluid (14.5% vs 2.2%), discordant fetal growth (41.6% vs 22.8%) and rate of preterm delivery (66.6% vs 32.6%). Related to the newborn we verified that they had a lower average birth weight (1988g vs 2295g), a highly rate of weight discordancy (23% vs 15.3%), intraventricular haemorrhage (2.2% vs 0%) and IUGR (6.6% vs 1.6%), statistically significant in the monochorionic group. Also the perinatal mortality rate was significantly higher in the monochorionic pregnancies (93.7 per thousand vs 21.7 per thousand). CONCLUSION: The high rate of morbidity and mortality related to the monochorionic twin pregnancies, implies the need of a correct identification of the type of chorionicity and also a high standard of prenatal surveillance in prenatal specialised health centers.

[Hypercalcemic crisis associated with primary hyperparathyroidism during pregnancy]. / Crise hipercalcémica secundária a hiperparatiroidismo primário durante a gravidez.

Primary hyperparathyroidism is a rare occurrence in pregnancy with significant risks to the mother and the foetus, witch is related to the level of serum calcium. A 41-year-old women, gravida 2, para 1, presented at 22 weeks gestation with nausea, vomiting and mild cognitive dysfunction associated with hypercalcemic crisis. The hypercalcemia was observed to be related to parathyroid hyperplasia that was surgically removed. Complete resolution of her symptomatology and hypercalcemia occurred postoperatively. The pregnancy was complicated with transient hypertension. A small for gestational age healthy male infant was delivered at term with no neonatal complications related with this pathology.