Da formação por competências às EPAs / From competency-based training to EPAs

A Comissão Nacional de Residência Médica da Febrasgo trabalhou nos últimos anos para a criação da Matriz de Competências em Ginecologia e Obstetrícia, e orgulhosamente foi a primeira Matriz de Competências entre as diversas especialidades médicas, sendo a versão 2 publicada em 2019. Considerou-se a realidade local dos Programas de Residência Médica em Ginecologia e Obstetrícia e o nível profissional pretendido para servir à sociedade brasileira. Considera-se a Competência Médica como a capacidade médica verificável que integra os componentes de conhecimento, habilidades, atitudes e valores éticos. A Matriz de Competências é composta de 16 eixos e subdividida de acordo com os três anos de residência em Ginecologia e Obstetrícia. Uma forma interessante que contribui para a avaliação das competências de residentes são as atividades profissionais confiabilizadoras, conhecidas como EPAs.

Pooled incidence of continuation and pregnancy rates of four contraceptive methods in young women: a meta-analysis.

BACKGROUND: Continuation rates of contraceptive methods in young women vary among studies, and there is scarce data regarding the pregnancy rate in this population. METHODS: Four independently systematic searches were performed in PUBMED, EMBASE, LILACS, and Cochrane databases from inception until January 2021 for oral contraceptive pill (OCP), copper IUD, levonorgestrel intrauterine system (LNG-IUS), and subdermal implant. Inclusion criteria were observational or RCT studies that reported continuation for at least 12 months and/or pregnancy rate of these contraceptives methods in girls aged 22 years old or younger. Two authors extracted data from the study design and the outcomes. Pooled proportions of each method were applied using the inverse variance in all calculations with LOGIT transformation, using the random-effects model. Cochrane collaboration tool and New Castle-Ottawa were used to assess the quality and bias of all included studies. GRADE criteria evaluated the quality of evidence. RESULTS: Continuation rate for OCP was 51% (95%CI 34%-68%), while for cooper IUD was 77% (95%CI 74%-80%), LNG-IUS 84% (95%CI 80%-87%), and implant 85% (95%CI 81%-88%). The pooled estimated pregnancy rate for OCP was 11% (95%CI 6%-20%), while for cooper IUD was 5% (95%CI 3%-7%), LNG-IUS 1.6% (95%CI 1.2%-2.3%), and implant 1.8% (95%CI 0.4%-8.4%). CONCLUSION: Long-acting contraceptive methods presented higher continuation rates and lower pregnancy rates when compared to OCPs.

Current evidence of contraceptive uptake, pregnancy and continuation rates in young women: a systematic review and Meta-analysis.

OBJECTIVE: Half of all pregnancies worldwide are unintended, and the rate is even higher in women aged ≤25 years. We sought to identify which method of contraception was the most effective option to prevent unintended pregnancy in young women and adolescents. METHODS: Systematic searches, without language restrictions, were carried out of the PubMed, Embase, Lilacs and Cochrane databases from inception to July 2020. Abstracts and full-text articles of observational studies and randomised controlled trials comparing the use of multiple methods of long-acting reversible contraception (LARC) and short-acting reversible contraception (SARC) in young women and adolescents were screened and reviewed. Risk ratios (RRs) and mean differences with their 95% confidence interval (CI) were derived using a random-effects meta-analytical model. Meta-analyses provided pooled estimates for adverse events, continuation rates and efficacy of LARC methods in young women and adolescents. Nine of the 25 included studies compared LARC with SARC, and 16 compared LARC methods only. RESULTS: At 12 months, young women had better adherence with LARC compared with SARC (n = 1606; RR 1.60; 95% CI 1.21, 2.12; I 2 = 88%), which suggests a better unintended pregnancy prevention outcome for young women. However, more young women chose SARC (n = 2835; RR 0.37; 95% CI 0.17, 0.80; I 2 = 99%). Pregnancy during LARC use was rare. CONCLUSION: LARC methods are the most efficacious in preventing pregnancy, and women should be informed of this if pregnancy prevention is their priority. The evidence, however, is of low quality. PROSPERO REGISTRATION NUMBER: CRD42017055452.

Síndrome de burnout durante a residência médica / Burnout syndrome during medical residency

No presente artigo, a Comissão Nacional Especializada em Residência Médica da Febrasgo traz à tona elementos essenciais para conhecer, reconhecer e prevenir a síndrome de burnout em médicos-residentes de ginecologia-obstetrícia. (AU)

Contraception and family planning at the extreme of reproductive life-climacteric / Anticoncepção e planejamento familiar no extremo da vida reprodutiva-climatério

SUMMARY Menopause is an endocrine phenomenon characterized by gradual estrogen decline. This is a stage in a woman's life in which contraception is extremely important as the risks associated with pregnancy and childbirth increase, both maternal issues associated with higher incidence of comorbidities and issues related to fetal abnormalities, mitochondrial abnormalities, or genetic syndromes. On the other hand, there is a growing number of women who have postponed motherhood and need effective contraception, but without prolonging the return to fertility. Long-acting reversible contraceptives (LARCs), low-dose oral hormonal contraceptives and non-oral contraceptives are preferred. The levonorgestrel-releasing intrauterine system is a very good alternative that can maintain endometrial protection after menopause. Definitive methods such as tubal ligation and vasectomy are options for couples that already have their offspring. In this review, we present evidence for contraceptive indication and the effects of hormonal methods on climacteric including options for contraception, control of bleeding during perimenopause and of climacteric symptoms, as well as the transition from such methods to hormone therapy if indicated.

Resumo O climatério é um fenômeno endócrino caracterizado pelo gradativo declínio estrogênico. Esta é uma fase da vida da mulher em que a contracepção tem crescente importância, uma vez que crescem os riscos no ciclo gravídico-puerperal, seja por questões maternas, associadas à maior incidência de comorbidades, seja por questões ligadas a malformações fetais, anormalidades mitocondriais ou síndromes genéticas. Por outro lado, é cada vez maior o número de mulheres que tem postergado a maternidade, necessitando de contracepção eficiente; porém, que não prolongue o retorno à fertilidade. Dá-se preferência para métodos contraceptivos de longa duração (LARC), baixas doses hormonais orais e administradas por vias não orais. O sistema intrauterino liberador de levonorgestrel é ótima alternativa, podendo manter proteção endometrial na pós-menopausa. Os métodos definitivos, como laqueadura e vasectomia, são opções para o casal com prole constituída. Nesta revisão apresentamos evidências para indicação e efeitos dos métodos hormonais no climatério, como opções contraceptivas, para controle de sangramento perimenopausa e de sintomas climatéricos, bem como a transição destes para a terapia hormonal quando indicada.

Contraception and family planning at the extreme of reproductive life - climacteric.

Menopause is an endocrine phenomenon characterized by gradual estrogen decline. This is a stage in a woman's life in which contraception is extremely important as the risks associated with pregnancy and childbirth increase, both maternal issues associated with higher incidence of comorbidities and issues related to fetal abnormalities, mitochondrial abnormalities, or genetic syndromes. On the other hand, there is a growing number of women who have postponed motherhood and need effective contraception, but without prolonging the return to fertility. Long-acting reversible contraceptives (LARCs), low-dose oral hormonal contraceptives and non-oral contraceptives are preferred. The levonorgestrel-releasing intrauterine system is a very good alternative that can maintain endometrial protection after menopause. Definitive methods such as tubal ligation and vasectomy are options for couples that already have their offspring. In this review, we present evidence for contraceptive indication and the effects of hormonal methods on climacteric including options for contraception, control of bleeding during perimenopause and of climacteric symptoms, as well as the transition from such methods to hormone therapy if indicated.

Pre-participation gynecological evaluation of female athletes: a new proposal.

OBJECTIVE: To propose the inclusion of a gynecological investigation during the evaluation of athletes before competitions, using a specific instrument called the Pre-participation Gynecological Examination (PPGE). METHODS: The study assessed 148 athletes, mean age of 15.4±2.0 years, who engaged in eight different sports modalities, and who responded to a questionnaire named Pre-Participation Gynecological Examination (PPGE), to the International Consultation on Incontinence Questionnaire - Short Form (for urinary loss), and to the Eating Attitudes Test (for eating disorders). RESULTS: Fifty percent of the participants reported irregular menstrual intervals, 23.0% did not know about sexually transmitted diseases, and 72.4% denied having, at least, an annual gynecological appointment. The study identified 18.2% who had urinary loss, and 15% presented with an increased risk of eating disorders. Moreover, 89.9% were not familiar with the occurrence of urinary incontinence in athletes and did not know that they were susceptible to the female athlete triad. A total of 87.1% of them stated that would not mention these issues to their coaches even if this would improve their health or performance. CONCLUSION: The Pre-Participation Gynecological Examination can be considered an easy-to-apply instrument that allowed the diagnosis of alterations often underestimated by the athletes themselves. After its application, the alterations were identified, and determined the athletes' referral to appropriate evaluation and treatment.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil.

PURPOSE: To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS: A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fisher's exact test. RESULTS: The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm(2), respectively, versus 12.4 cm(2) in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION: Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

Assessment of pelvic floor by three-dimensional-ultrasound in primiparous women according to delivery mode: initial experience from a single reference service in Brazil / Avaliação do assoalho pélvico por meio da ultrassonografia tridimensional de mulheres primíparas de acordo com o tipo de parto: experiência inicial de um centro de referência do Brasil

PURPOSE: To evaluate changes to the pelvic floor of primiparous women with different delivery modes, using three-dimensional ultrasound. METHODS: A prospective cross-sectional study on 35 primiparae divided into groups according to the delivery mode: elective cesarean delivery (n=10), vaginal delivery (n=16), and forceps delivery (n=9). Three-dimensional ultrasound on the pelvic floor was performed on the second postpartum day with the patient in a resting position. A convex volumetric transducer (RAB4-8L) was used, in contact with the large labia, with the patient in the gynecological position. Biometric measurements of the urogenital hiatus were taken in the axial plane on images in the rendering mode, in order to assess the area, anteroposterior and transverse diameters, average thickness, and avulsion of the levator ani muscle. Differences between groups were evaluated by determining the mean differences and their respective 95% confidence intervals. The proportions of levator ani muscle avulsion were compared between elective cesarean section and vaginal birth using Fisher's exact test. RESULTS: The mean areas of the urogenital hiatus in the cases of vaginal and forceps deliveries were 17.0 and 20.1 cm², respectively, versus 12.4 cm² in the Control Group (elective cesarean). Avulsion of the levator ani muscle was observed in women who underwent vaginal delivery (3/25), however there was no statistically significant difference between cesarean section and vaginal delivery groups (p=0.5). CONCLUSION: Transperineal three-dimensional ultrasound was useful for assessing the pelvic floor of primiparous women, by allowing pelvic morphological changes to be differentiated according to the delivery mode.

OBJETIVO: Avaliar as mudanças no assoalho pélvico de mulheres primíparas em diversos tipos de partos por meio da ultrassonografia tridimensional. MÉTODOS: Estudo de corte transversal prospectivo com 35 primigestas, divididas em grupos com relação ao tipo de parto: cesariana eletiva (n=10), parto vaginal (n=16) e fórceps (n=9). A ultrassonografia tridimensional do assoalho pélvico foi realizada no segundo dia pós-parto com a paciente em repouso. Utilizou-se transdutor convexo volumétrico (RAB4-8L) em contato com os grandes lábios vaginais, estando a paciente em posição ginecológica. Medidas biométricas do hiato urogenital foram tomadas no plano axial da imagem renderizada para avaliar a área, os diâmetros anteroposterior e transverso, a espessura média e a avulsão do músculo elevador do ânus. Diferenças entre os grupos foram avaliadas pela determinação da média das diferenças com seus respectivos intervalos de confiança de 95%. As proporções de avulsão do músculo elevador do ânus foram comparadas entre a cesárea eletiva e o parto vaginal pelo teste exato de Fisher. RESULTADOS: As áreas médias do hiato urogenital dos partos vaginais e fórceps foram 17,0 e 20,1 cm², respectivamente, contra 12,4 cm² do Grupo Controle (cesárea eletiva). Avulsão do músculo elevador do ânus foi observado em mulheres submetidas ao parto vaginal (3/25); no entanto, não houve diferença significativa entre os grupos cesárea e parto vaginal (p=0,5). CONCLUSÃO: A ultrassonografia tridimensional por via perineal foi útil na avaliação do assoalho pélvico de mulheres primíparas, diferenciando alterações pélvicas de acordo com o tipo de parto.