Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Transabdominal and transperineal ultrasound vs routine care before instrumental vaginal delivery - A randomized controlled trial.

INTRODUCTION: The role of intrapartum ultrasound as an ancillary method to instrumental vaginal delivery is yet to be determined. This study aimed to compare the use of transabdominal and transperineal ultrasound with routine clinical care before performing an instrumental vaginal delivery, regarding the incidence of adverse maternal and neonatal outcomes. MATERIAL AND METHODS: A randomized controlled trial was conducted between October 2016 and March 2019 in two tertiary care maternity hospitals in Lisbon, Portugal. Women at term, with full cervical dilatation, singleton fetuses in cephalic presentation, and with an established indication for instrumental vaginal delivery, were approached for enrollment. After informed consent was obtained, randomization into one of two groups was carried out. In the experimental arm, women underwent transabdominal ultrasound for determination of the fetal head position and transperineal ultrasound for evaluation of the angle of progression, before instrumental vaginal delivery. In the control arm, no ultrasound was carried out before instrumental vaginal delivery. Primary outcomes were composite measures of maternal and neonatal morbidity. Composite maternal morbidity consisted of severe postpartum hemorrhage, perineal trauma, and prolonged hospital stay. Composite neonatal morbidity consisted of low 5-minute Apgar score, umbilical artery metabolic acidosis, birth trauma, and neonatal intensive care unit admission. RESULTS: A total of 222 women were enrolled (113 in the experimental arm and 109 in the control arm). No significant differences between the two arms were found in composite measures of maternal (23.9% in the experimental group vs 22.9% in the control group, odds ratio 1.055, 95% CI 0.567-1.964) or neonatal morbidity (9.7% in the experimental group vs 6.4% in the control group, odds ratio 1.571, 95% CI 0.586-4.215), nor in any of the individual outcomes. CONCLUSIONS: In this small randomized controlled trial that was stopped for futility before reaching the required sample size, transabdominal and transperineal ultrasound performed just before instrumental vaginal delivery did not reduce the incidence of adverse maternal and neonatal outcomes, when compared with routine clinical care.

Effect of simulation-based training on the accuracy of fetal head position determination in labor.

OBJECTIVES: The objective of this study was to evaluate the effect of simulation-based training on the accuracy of fetal head position determination by junior residents during the second stage of labour. STUDY DESIGN: This prospective study was conducted in a tertiary care university hospital. During an initial period of 12 weeks, 13 junior residents were asked to routinely evaluate fetal head position by digital examination during the second stage of labour, in women with term singletons in cephalic presentation. Digital examination was followed immediately by transabdominal ultrasound to confirm fetal head position, performed by an experienced physician. Following this initial period, all participants attended a workshop where simulation-based training of fetal head position determination was provided. A second 12-week period was subsequently completed, with similar characteristics to the initial one. The accuracy of clinical evaluations was assessed by the percentage of exact evaluations, the percentage of correct evaluations within a 45° error margin, and by Cohen's kappa coefficient of agreement. RESULTS: A total of 83 observations were performed in the initial period of the study and 74 observations were performed in the second period. The accuracy of fetal head position determination during the first period of the study was 59.0% (95% CI 47.7-69.7), k = 0.517 (95%CI 0.391 - 0.635), corresponding to a moderate agreement. Considering a 45° margin of error, accuracy was 71.1% (95% CI 60.1-80.5), k = 0.656 (95% CI 0.538 - 0.763), corresponding to substantial agreement. Following simulation-based training, the accuracy of fetal head position determination was 70.3% (95% CI 58.5-80.3), k = 0.651 (95% CI 0.526 - 0.785), corresponding to a substantial agreement. Considering a 45° margin of error, accuracy was 78.4% (95% CI 67.3-87.1), k = 0.745 (95% CI 0.631 - 0.854), corresponding to a substantial agreement. CONCLUSIONS: Although a trend towards increased accuracy in fetal head position determination was observed after simulation-based training, the difference was not statistically significant. Further studies are needed to clarify the role of simulation-based training for fetal head position determination during residency.

Small-for-gestational-age babies of low-risk term pregnancies: does antenatal detection matter?

OBJECTIVES: To compare delivery route and admission rate to neonatal intensive care unit between small- and appropriate-for-gestational-age babies among low-risk term pregnancies. METHODS: A retrospective study was conducted using the database of deliveries in 2014 at a tertiary hospital. Babies delivered at ≥37 weeks with birthweight <10th centile were considered small-for-gestational-age (SGA) and >90th centile were considered large-for-gestational-age. Fetal weight estimation at 30-33 weeks ultrasound <10th centile was considered antenatal detection of SGA. RESULTS: Among 1429 low-risk term pregnancies, 11% (151/1429) had SGA babies and 5% (75/1429) had large-for-gestational-age. SGA babies were associated with higher rate of cesarean sections for nonreassuring fetal status (18/151 versus 8/1202, p < .001) and higher rate of admissions to neonatal intensive care unit (16/151 versus 18/1202, p < .001) compared to appropriate-for-gestational-age. Within SGA group, antepartum detected fetuses were associated with lower rate of operative deliveries for nonreassuring fetal status than undetected group (3/31 versus 39/120, p = .01) Conclusions: In our series, women with SGA term babies were associated with more adverse obstetric and neonatal outcome than appropriate-for-gestational age, especially among those undetected prenatally.

Impact of maternal weight on the intra-observer and inter-observer reproducibility of fetal ultrasonography measurements in the third trimester.

OBJECTIVE: To evaluate the effect of maternal weight on the intra- and inter-observer reproducibility of third-trimester ultrasonography fetal measurements. METHODS: The present prospective study, performed at a tertiary hospital, enrolled patients at between 35+0  weeks and 36+6  weeks of singleton pregnancies between January 1, 2015, and July 1, 2016. Fetal ultrasonography measurements were evaluated twice by a first observer and a third time by a second observer. Intra- and inter-observer consistency were analyzed using the Cronbach α reliability coefficient, and measurement reproducibility was compared with patients stratified by a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of below 25 or at least 25. RESULTS: The study included 197 patients (133 with BMI <25 and 64 with BMI ≥25). Among patients with a BMI below 25, the reliability coefficients for bi-parietal diameter, head circumference, abdominal circumference, and femur length measurements were 0.97, 0.95, 0.98, and 0.96, respectively, for intra-observer consistency, and were 0.97, 0.93, 0.98, and 0.95, respectively, for inter-observer consistency. Among patients with a BMI of at least 25, these values were 0.97, 0.96, 0.98, and 0.97, respectively, for intra-observed consistency, and 0.97, 0.94, 0.98, and 0.96, respectively, for inter-observer consistency. CONCLUSION: High intra- and inter-observer reproducibility was observed for third-trimester fetal ultrasonography measurements, including for patients who were overweight.

Agreement and accuracy using the FIGO, ACOG and NICE cardiotocography interpretation guidelines.

INTRODUCTION: One of the limitations reported with cardiotocography is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of cardiotocography interpretation using the International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines. MATERIAL AND METHODS: A total of 151 tracings were evaluated by 27 clinicians from three centers where International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines were routinely used. Interobserver agreement was evaluated using the proportions of agreement and reliability with the κ statistic. The accuracy of tracings classified as "pathological/category III" was assessed for prediction of newborn acidemia. For all measures, 95% confidence interval were calculated. RESULTS: Cardiotocography classifications were more distributed with International Federation of Gynecology and Obstetrics (9, 52, 39%) and National Institute for Health and Care Excellence (30, 33, 37%) than with American College of Obstetrics and Gynecology (13, 81, 6%). The category with the highest agreement was American College of Obstetrics and Gynecology category II (proportions of agreement = 0.73, 95% confidence interval 0.70-76), and the ones with the lowest agreement were American College of Obstetrics and Gynecology categories I and III. Reliability was significantly higher with International Federation of Gynecology and Obstetrics (κ = 0.37, 95% confidence interval 0.31-0.43), and National Institute for Health and Care Excellence (κ = 0.33, 95% confidence interval 0.28-0.39) than with American College of Obstetrics and Gynecology (κ = 0.15, 95% confidence interval 0.10-0.21); however, all represent only slight/fair reliability. International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence showed a trend towards higher sensitivities in prediction of newborn acidemia (89 and 97%, respectively) than American College of Obstetrics and Gynecology (32%), but the latter achieved a significantly higher specificity (95%). CONCLUSIONS: With American College of Obstetrics and Gynecology guidelines there is high agreement in category II, low reliability, low sensitivity and high specificity in prediction of acidemia. With International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence guidelines there is higher reliability, a trend towards higher sensitivity, and lower specificity in prediction of acidemia.

Prevalence of Late Preterm and Early Term Birth in Portugal.

INTRODUCTION: Late preterm birth (defined as birth between 34 and 36 complete weeks' gestation) and early term birth (defined as birth between 37 and 38 complete weeks' gestation) have become a topic of recent discussion as the morbidity associated with delivery at these gestational ages has become increasingly evident. Our objective was to evaluate the characteristics of late preterm and early term birth in Portugal. MATERIAL AND METHODS: We developed a survey questionnaire that was sent to the Obstetric Department of all public hospitals in Portugal. The questionnaire consisted on questions on prevalence and mode of delivery of late preterm and early term period and associated neonatal morbidity and mortality. The questions referred solely to single births occurred during 2013. RESULTS: We received completed questionnaires from 14 hospitals, corresponding to nearly one third (33.5%) of total deliveries in Portugal. We report 5.4% of late preterm and 27% of early term deliveries. Approximately two thirds of late preterm and three quarters of early term deliveries were spontaneous. The cesarean section rate was higher in late preterm (39.1%) than in early term (26.4%) births. Neonatal complications were more frequent in late preterm neonates (34.2%) when compared to early term neonates (14.2%). DISCUSSION: The prevalence of late preterm and early term birth in our cohort is comparable, although slightly reduced, to other published series. CONCLUSION: The obstetric community should raise efforts to limit deliveries below 39 weeks' gestation to the ones with a valid medical indication.

Introdução: Nos últimos anos, vários autores evidenciaram a morbilidade associada aos partos ocorridos entre as 34 e 36 semanas (pré-termo tardio) e entre as 37 e 38 semanas de gestação (termo precoce). Neste sentido, pretendemos realizar um estudo epide-miológico dos partos que ocorrem nestas idades gestacionais, em Portugal. Material e Métodos: Realizámos um inquérito, que foi aplicado a todos os hospitais públicos de Portugal, acerca da prevalência e via de parto nos partos pré-termo tardios e de termo precoce, e morbilidade e mortalidade neonatal associada. As questões referiam-se apenas a gestações de feto único e a partos ocorridos em 2013. Resultados: Incluímos 14 hospitais, correspondendo a 33,5% dos partos ocorridos em Portugal, em 2013. Verificámos que 5,4% dos partos ocorreram no período pré-termo tardio e 27% no termo precoce. Aproximadamente dois terços dos partos pré-termo tardio e três quartos dos partos de termo precoce foram espontâneos. A taxa de cesariana foi mais elevada entre as 34 e 36 semanas de gestação (39,1%) do que entre as 37 e 38 semanas (26,4%). As complicações neonatais foram mais frequentes após um parto pré-termo tardio (34,2%), quando comparadas com os de termo precoce (14,2%). Discussão: Na nossa amostra, a prevalência de parto pré-termo tardio e de termo precoce, ainda que ligeiramente inferior, é comparável à publicada em estudos anteriores. Conclusão: Á importante que a comunidade obstétrica nacional adote atitudes no sentido de limitar os partos antes das 39 semanas de gestação. Assim, nestas idades gestacionais os partos devem possuir uma indicação médica válida.

Estimation of Fetal Weight during Labor: Still a Challenge.

OBJECTIVE: To evaluate the accuracy of fetal weight prediction by ultrasonography labor employing a formula including the linear measurements of femur length (FL) and mid-thigh soft-tissue thickness (STT). METHODS: We conducted a prospective study involving singleton uncomplicated term pregnancies within 48 hours of delivery. Only pregnancies with a cephalic fetus admitted in the labor ward for elective cesarean section, induction of labor or spontaneous labor were included. We excluded all non-Caucasian women, the ones previously diagnosed with gestational diabetes and the ones with evidence of ruptured membranes. Fetal weight estimates were calculated using a previously proposed formula [estimated fetal weight = 1687.47 + (54.1 x FL) + (76.68 x STT). The relationship between actual birth weight and estimated fetal weight was analyzed using Pearson's correlation. The formula's performance was assessed by calculating the signed and absolute errors. Mean weight difference and signed percentage error were calculated for birth weight divided into three subgroups: < 3000 g; 3000-4000 g; and > 4000 g. RESULTS: We included for analysis 145 cases and found a significant, yet low, linear relationship between birth weight and estimated fetal weight (p < 0.001; R2 = 0.197) with an absolute mean error of 10.6%. The lowest mean percentage error (0.3%) corresponded to the subgroup with birth weight between 3000 g and 4000 g. CONCLUSIONS: This study demonstrates a poor correlation between actual birth weight and the estimated fetal weight using a formula based on femur length and mid-thigh soft-tissue thickness, both linear parameters. Although avoidance of circumferential ultrasound measurements might prove to be beneficial, it is still yet to be found a fetal estimation formula that can be both accurate and simple to perform.

Estimation of Fetal Weight during Labor: Still a Challenge / Estimativa do peso fetal intraparto: ainda um desafio

Objective To evaluate the accuracy of fetal weight prediction by ultrasonography labor employing a formula including the linear measurements of femur length (FL) and mid-thigh soft-tissue thickness (STT). Methods We conducted a prospective study involving singleton uncomplicated term pregnancies within 48 hours of delivery. Only pregnancies with a cephalic fetus admitted in the labor ward for elective cesarean section, induction of labor or spontaneous labor were included. We excluded all non-Caucasian women, the ones previously diagnosed with gestational diabetes and the ones with evidence of ruptured membranes. Fetal weight estimates were calculated using a previously proposed formula [estimated fetal weight = [1] 1687.47 + (54.1 x FL) + (76.68 x STT). The relationship between actual birth weight and estimated fetal weight was analyzed using Pearson's correlation. The formula's performance was assessed by calculating the signed and absolute errors. Mean weight difference and signed percentage error were calculated for birth weight divided into three subgroups: < 3000 g; 3000-4000g; and > 4000 g. Results We included for analysis 145 cases and found a significant, yet low, linear relationship between birth weight and estimated fetal weight (p < 0.001; R2 = 0.197) with an absolute mean error of 10.6%. The lowest mean percentage error (0.3%) corresponded to the subgroup with birth weight between 3000 g and 4000 g. Conclusions This study demonstrates a poor correlation between actual birth weight and the estimated fetal weight using a formula based on femur length and mid-thigh soft-tissue thickness, both linear parameters. Although avoidance of circumferential ultrasound measurements might prove to be beneficial, it is still yet to be found a fetal estimation formula that can be both accurate and simple to perform.

Objetivo Avaliar a precisão da determinação ultrassonográfica da estimativa de peso fetal recorrendo apenas a parâmetros lineares (comprimento do fémur - FL - e espessura de tecido mole a meio da coxa fetal - STT), no período precedente ao parto. Métodos Realizamos umestudo prospectivo que incluiu gestações simples de termo, comfeto cefálico, nas quais o parto ocorreu nas 48h seguintes à avaliação ecográfica. A inclusão no estudo foi feita nomomento de admissão ao bloco de partos para cesariana eletiva, indução do trabalho de parto ou trabalho de parto espontâneo. Foram excluídas todas as grávidas não caucasianas, com diagnóstico de diabetes gestacional ou evidência de rotura de membranas. A estimativa de peso fetal foi calculada através de uma fórmula previamente publicada [estimativa de peso fetal = [1]1687,47 + (54,1 x FL) + (76,68 x STT). A relação entre o peso real e o peso estimado foi analisada através da correlação de Pearson. O desempenho desta fórmula foi avaliado através do cálculo da percentagem de erro absoluto e não absoluto. Os recém-nascidos foram divididos em3 grupos consoante o peso real: < 3000 g; 3000 g - 4000 g; e > 4000 g; para cada grupo foi calculada diferençamédia entre a estimativa de peso e o peso real e a percentagem de erro associada. Resultados Incluímos 145 casos no estudo, cuja estimativa de peso e peso real se correlacionaram significativamente, apesar do valor de correlação ser pouco elevado (p < 0,001; R2 = 0,197). Globalmente, a percentagem de erro absoluto foi 10,6%. A percentagem de erro mais baixa correspondeu ao grupo com peso real entre 3000 g e 4000 g. Conclusões Comeste estudo demonstramos uma correlação fraca entre o peso real e a estimativa de peso fetal ultrassonográfica, quando calculada combase numa fórmula que usa o comprimento do fémur e a espessura de tecido mole a meio da coxa fetal, ambos parâmetros lineares. Ainda que a exclusão de parâmetros circunferenciais no cálculo da estimativa de peso fetal se venha a provar benéfica, esta não parece ser uma fórmula simultaneamente simples e precisa no cálculo da estimativa de peso fetal.

Intra-abortion contraception with etonogestrel subdermal implant.

OBJECTIVES: Etonogestrel subdermal implant is a highly effective, reversible and safe form of contraception. Immediate placement during abortion visit could increase contraception use in women at high risk for unintended pregnancy. Our purpose was to evaluate patient acceptability, user continuation rate and efficacy of medical termination of pregnancy when the implant is inserted during medical termination of pregnancy. STUDY DESIGN: Prospective observational study comparing patients who chose the subdermal implant for post-abortion contraception, inserted at the time of administration of mifepristone, with patients who chose delayed placement after the termination was complete. RESULTS: After contraceptive counseling 119 women chose the implant as their post-abortion contraceptive method. In the intra-abortion implant insertion group the user continuation rate after 6 months was 73.7% (42/57). In the delayed placement group 59.7% (37/62) missed the follow-up after abortion visit, 24.2% (15/62) chose another method and only 16.1% (10/62) had the implant inserted. The efficacy of medical termination was 96.5% in the group of intra-abortion implant insertion and 98.4% in the delayed placement group. CONCLUSIONS: Intra-abortion subdermal implant insertion significantly increases the likelihood of effective long-acting contraception use following abortion. The efficacy of medical termination was not significantly changed by intra-abortion implant insertion.

Ultrasound antenatal detection of urinary tract anomalies in the last decade: outcome and prognosis.

OBJECTIVE: This study has been undertaken to determine the frequency and pattern of urinary tract anomalies diagnosed by ultrasound, to correlate the prenatal with postnatal diagnoses and to identify prognostic factors. METHODS: The Ultrasound Unit's database was reviewed for fetal urinary tract anomalies detected between January 2002 and June 2012. Prenatal diagnoses made by ultrasound were confirmed by postnatal ultrasound, as well as with surgical reports. Statistical analysis was performed using the Mann-Whitney U-test, Chi-square and Fisher's exact tests. p values <0.05 were considered significant. RESULTS: A total of 838 fetal malformations were prenatally diagnosed by ultrasound with a frequency of 21% of urinary tract anomalies (177/838). Renal pelvis dilatation and hydronephrosis accounted for more than half of the cases (52%). The most frequent postnatal diagnoses were also urinary tract dilatations. The prenatal diagnoses corresponded to the postnatal ones in 88.8% of cases. There was a highly significant association between anterior-posterior renal pelvis diameter above 10 mm in the last ultrasound performed before the birth and the need for surgery (p < 0.01). CONCLUSION: We emphasize the high degree of reliability of prenatal ultrasound in the establishment of diagnosis of urinary tract malformations and the prediction of postnatal outcomes.

Route of delivery following successful external cephalic version.

OBJECTIVE: To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV). METHODS: A retrospective matched case-control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status. RESULTS: Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63). CONCLUSION: Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.

Elective removal of cervical cerclage and onset of spontaneous labor.

OBJECTIVE: To determine the time interval between elective removal of cervical cerclage and onset of spontaneous labor. METHODS: A retrospective cohort study was conducted between January 2005 and December 2012 at a tertiary care hospital in Lisbon, Portugal. All singleton pregnancies with a McDonald or Shirodkar cerclage electively removed at 36-37 weeks were evaluated for the time interval between cerclage removal and spontaneous labor. Delivery within 72 hours after cerclage removal was compared between patients with elective cerclage and those with non-elective cerclage. In the non-elective group, a sub-analysis of the results for ultrasound- and physical examination-indicated cerclage was performed. RESULTS: Thirty-eight women were included. The time interval between cerclage removal and spontaneous labor did not differ significantly between the elective and the non-elective group (15.6±7.6 vs 10.9±7.4 days; P=0.063). A higher incidence of delivery 72 hours after cerclage removal was seen in the non-elective group but this was not significant (P=0.061). There were no differences regarding the time interval from elective removal of cervical cerclage to onset of spontaneous labor between ultrasound-indicated and physical examination-indicated cerclage. CONCLUSION: Regardless of the indication for cervical cerclage, the probability of delivery soon after elective cerclage removal is low.

Acute fetal asphyxia after gastric rupture in a pregnant patient with a gastric band.

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.

Indications for cesarean deliveries during a 7-year period in a tertiary hospital.

INTRODUCTION: To analyze the cesarean section rate evolution in a tertiary hospital and the main indications for cesarean section. MATERIAL AND METHODS: A retrospective study was conducted at a major academic hospital and included 5 751 women who had a cesarean section from 2005 to 2011. The rates of overall, primary and repeat cesarean sections were analyzed. A linear regression and adjusted R-square were used to access the relative contribution of each indication to the variation in primary cesarean section. RESULTS: During the 7-year period of the study the cesarean section rate decreased from 30.9% to 27.6%. This was due to a decrease in primary cesarean section (21.9% to 18.2%), although an increase in repeat cesarean section was observed (9.0% to 9.4%). Among the indications for primary cesarean section, maternal-fetal indications and malpresentation were the ones that decreased the most with adjusted R-square of 0.70 and 0.55, respectively. DISCUSSION: The collected data identified that the decrease in the cesarean section rate at the hospital resulted from a decrease in primary cesarean section deliveries, especially the ones performed for maternal-fetal indications and malpresentation. CONCLUSION: The decrease in primary cesarean section rate may be attributed to several changes in medical policies in the Department, such as the implementation of an external fetal version program, the induction of labor only after the 41st week of gestation in low-risk pregnancies and the trial for vaginal birth in maternal-fetal disease. Nevertheless subjective indications such as labor arrest disorders and nonreassuring fetal heart rate are still major contributors for primary cesarean section rate.

Introdução: Analisar a evolução da taxa de cesarianas e as principais indicações para cesariana num centro terciário.Material e Métodos: Estudo retrospectivo conduzido num hospital universitário que incluiu 5751 grávidas submetidas a cesariana entre 2005 e 2011. Analisaram-se as taxas de cesarianas, incluindo a taxa de primeiras cesarianas e de cesarianas repetidas. Para avaliar a contribuição relativa de cada uma das indicações na variação da taxa de primeiras cesarianas recorreu-se à regressão linear e determinou-se o valor do r2 ajustado.Resultados: Durante o período do estudo a taxa de cesarianas diminuiu de 30,9% para 27,6%. Esta descida deveu-se à diminuição da taxa de primeiras cesarianas (21,9% para 18,2%), apesar de se ter constatado um ligeiro aumento da taxa de cesarianas repetidas (9,0 para 9,4%). Entre as indicações para primeiras cesarianas, as causas materno-fetais e de apresentação anómala foram as que diminuiram mais, com valores de r2 ajustado de 0,70 e 0,55, respectivamente.Discussão: Os dados coligidos permitiram identificar a hipótese de que a diminuição da taxa de cesarianas se deveria a uma retração detectada sobretudo a nível das primeiras cesarianas, em particular as decorrentes de causas materno-fetais e apresentação anómala.Conclusão: A diminuição da taxa de primeiras cesarianas pode ser atribuída a várias modificações na prática clínica do Departamento, como a implementação da versão cefálica externa, a indução do trabalho de parto a partir das 41 semanas de gestação, em gravidezes de baixo risco e da realização de provas de trabalho de parto em casos de patologia materno-fetal. No entanto, indicações subjectivas, como a paragem de progressão do trabalho de parto e a suspeita de sofrimento fetal são ainda causas major de primeiras cesarianas.

Labor induction with 25-microg misoprostol vaginal capsules.

AIM: To evaluate the success rate and the safety profile of labor induction with a new misoprostol formulation - vaginal capsules of 25 microg of misoprostol. METHODS: Labor induction was performed in 250 singleton term pregnancies; 149 (59.6%) were nulliparous. Vaginal capsules of 25 microg of misoprostol were placed in the posterior vaginal fornix every 6 h. Success rate, contractility and fetal heart rate abnormalities and fetal outcomes were evaluated. RESULTS: The success rate of labor induction was 97.6%. The average number of vaginal administrations was 1.5. The mean interval between induction and active labor was 10 h and 20 min and the average length of labor was 15 h and 35 min. The cesarean section rate was 18.8%. There were 15 cases of tachysystole, 3 cases of hypertonus and 1 case of hyperstimulation syndrome. There were no adverse neonatal outcomes. CONCLUSIONS: This study allowed to conclude that labor induction with vaginal capsules of 25 microg of misoprostol is associated with an excellent success rate and safety profile.

Pregnancy after a previous gestation complicated by an acute aortic dissection.

Acute aortic dissection is a rare life-threatening event. No further pregnancies in women who had a previous acute aortic dissection have been reported. We present the case of a chronic hypertensive woman, who in her previous gestation was submitted to an acute aortic dissection repair at 28 weeks of gestation with cesarean delivery at the same operative procedure. The index pregnancy was uneventful. An elective cesarean was performed at 33 weeks' gestation. Aneurysm expansion, rupture or redissections are potential complications of operated aortic dissection. Normal blood pressure values and close cardiologic and obstetrical follow-up are essential to obtain a favourable outcome.