Pelvic floor muscle function after grade II tears-Surface electromyography test-retest and differences between nulliparous and primiparous.

BACKGROUND: Vaginal birth is a risk factor for weakening of the pelvic floor muscles (PFM) and development of pelvic floor dysfunction (PFD). Perineal tears may decrease PFM function. PFM tone can be assessed with surface EMG (sEMG), but reliability studies of sEMG in women with perineal tears are lacking. The aims of this study were to evaluate test-retest and intrarater reliability of sEMG and compare PFM activation between nulliparous and primiparous. METHODS: A sEMG test-retest was performed in 21 women (12 nulliparous and 9 primiparous with grade II tears) to assess intra-rater reliability during rest and maximal voluntary contraction (MVC) of the PFM. Intraclass Correlation Coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were tested. A comparison between nulliparous' and primiparous' PFM activation during rest and MVC was performed. RESULTS: sEMG demonstrated fair reliability in nulliparous (ICC: 0.239; SEM: 5.2; MDC: 14.5) and moderate reliability in primiparous (ICC: 0.409; SEM: 1.5; MDC: 4.2) during rest. For peak MVC very good intrarater reliability was found in nulliparous (ICC: 0.92; SEM: 8.0; MDC: 22.2) and in primiparous (ICC: 0.823; SEM: 8.0; MDC: 22.2). Statistically significant lower PFM activation was found in primiparous women with perineal tear grade II than in nulliparous at rest (mean difference 9.1 µV, 95% confidence interval [CI] 3.0-19.0, p = 0.001), and during MVCpeak (mean difference 50.0 µV, 95% CI 10.0-120.0 p = 0.021). CONCLUSIONS: sEMG is reliable when measuring PFM activation in primiparous women with perineal tears grade II. Women with perineal tears grade II have lower PFM activation both during rest and MVC.

Uterine preservation with Alcides-Pereira's compressive sutures for postpartum uterine atony.

INTRODUCTION: Postpartum hemorrhage (PPH) is mostly caused by uterine atony and is the leading cause of maternal death. Hysterectomy may be necessary in severe cases, but uterine compressive sutures are an uterine-sparing alternative. In 2005, Alcides Pereira proposed a technique with serial superficial stiches around the uterus. To date, there were no further reports on its clinical use. OBJECTIVE: To evaluate a tertiary center's experience with Alcides-Pereira's compressive uterine sutures for severe PPH due to uterine atony, reviewing its efficacy, morbidity, and impact on reproductive outcomes. STUDY DESIGN: An 11-year retrospective cohort study of Alcides-Pereira's sutures for PPH at a single tertiary hospital. Demographic and obstetric data were collected. Details of subsequent pregnancies and fertility plans were collected through a telephonic interview. Comparison between women in which the sutures were effective and ineffective to prevent hysterectomy was made. RESULTS: Alcides-Pereira's sutures were applied in 23 patients with PPH due to uterine atony. The technique was successful in controlling the hemorrhage and avoiding hysterectomy in 20 patients (87%). When successful, the sutures avoided the need for any blood therapy in 55% (RR 0.45, 95% CI 0.28-0.73) of patients, intensive care unit admission in 80% (RR 0.2, 95% CI 0.08-0.48) and significantly shortened the length of hospital stay. All patients with preserved uterus resumed their usual menstrual pattern. One had a subsequent term vaginal delivery; one had three first trimester miscarriages. All other patients did not try to conceive. CONCLUSION: Alcides-Pereira's sutures are a feasible, uterine-sparing technique, providing an effective and safe option for PPH.

[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.

European guidelines on perinatal care- Peripartum care Episiotomy.

OF RECOMMENDATIONS1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++-; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation)2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation).3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++-; Strong recommendation).4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation).

European Guidelines on Perinatal Care - Oxytocin for induction and augmentation of labor[Formula: see text].

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).[Table: see text]6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

A fetus with an immature umbilical cord teratoma associated with exomphalos: case report and review of the literature.

OBJECTIVE: To describe the antenatal and pathological features of an immature umbilical cord teratoma associated with exomphalos, and to review the literature on this subject. CASE PRESENTATION: An abdominal wall defect, suspected to be an exomphalos, was identified during routine ultrasound examination performed at 13 weeks of gestation. The pregnancy was terminated. Fetopathological examination revealed an immature umbilical cord teratoma associated with exomphalos. Chromosomal microarray analysis was normal. CONCLUSIONS: Umbilical cord teratomas, albeit very rare, should be emphasized as a possible differential diagnosis when abdominal wall defects are detected. Since cord teratomas may lead to adverse fetal or neonatal outcomes, close follow-up of the fetus is recommended.

Mueller-Hillis maneuver and angle of progression: Are they correlated?

OBJECTIVE:: Mueller-Hillis maneuver (MHM) and angle of progression (AOP) measured by transperineal ultrasound have been used to assess fetal head descent during the second stage of labor. We aimed to assess whether AOP correlates with MHM in the second stage of labor. METHOD:: A prospective observational study including women with singleton pregnancy in the second stage of labor was performed. The AOP was measured immediately after the Mueller-Hillis maneuver. A receiver-operating characteristics (ROC) curve analysis was performed to determine the best discriminatory AOP cut-off for the identification of a positive MHM. A p-value less than 0.05 was considered statistically significant. RESULTS:: One hundred and sixty-six (166) women were enrolled in the study and 81.3% (n=135) had a positive MHM. The median AOP was 143º (106º to 210º). The area under the curve for the prediction of a positive maneuver was 0.619 (p=0.040). Derived from the ROC curve, an AOP of 138.5º had the best diagnostic performance for the identification of a positive MHM (specificity of 65% and a sensitivity of 67%). CONCLUSION:: An AOP of 138º seems to be associated with a positive MHM in the second stage of labor.

Mueller-Hillis maneuver and angle of progression: Are they correlated? / Manobra de Mueller-Hillis e ângulo de progressão: eles estão correlacionados?

Summary Objective: Mueller-Hillis maneuver (MHM) and angle of progression (AOP) measured by transperineal ultrasound have been used to assess fetal head descent during the second stage of labor. We aimed to assess whether AOP correlates with MHM in the second stage of labor. Method: A prospective observational study including women with singleton pregnancy in the second stage of labor was performed. The AOP was measured immediately after the Mueller-Hillis maneuver. A receiver-operating characteristics (ROC) curve analysis was performed to determine the best discriminatory AOP cut-off for the identification of a positive MHM. A p-value less than 0.05 was considered statistically significant. Results: One hundred and sixty-six (166) women were enrolled in the study and 81.3% (n=135) had a positive MHM. The median AOP was 143º (106º to 210º). The area under the curve for the prediction of a positive maneuver was 0.619 (p=0.040). Derived from the ROC curve, an AOP of 138.5º had the best diagnostic performance for the identification of a positive MHM (specificity of 65% and a sensitivity of 67%). Conclusion: An AOP of 138º seems to be associated with a positive MHM in the second stage of labor.

Resumo Objetivo: A manobra de Mueller-Hillis (MHM) e o ângulo de progressão da apresentação (AOP) medido através de ecografia transperineal têm sido utilizados para avaliar a descida do polo cefálico durante o segundo estágio do trabalho de parto. O objetivo do nosso trabalho foi avaliar se o AOP se correlaciona com a MHM no segundo estágio do trabalho de parto. Método: Conduzimos um estudo observacional e prospectivo. Incluímos mulheres com gravidez unifetal com feto em apresentação cefálica, no segundo estágio do trabalho de parto. O AOP foi medido imediatamente após a manobra de Mueller-Hillis. Foi construída uma curva ROC (receiver-operating characteristics) para determinar o melhor AOP para a identificação de uma manobra positiva. Um valor p inferior a 0,05 foi considerado estatisticamente significativo. Resultados: Cento e sessenta e seis mulheres (166) foram incluídas no estudo, e em 81,3% (n=135) a MHM foi positiva. A mediana do AOP foi de 143º (106º a 210º). A área abaixo da curva para a previsão de uma manobra positiva foi 0,619 (p=0,040). Derivado da curva ROC, um AOP de 138,5º teve o melhor desempenho diagnóstico para a identificação de uma MHM positiva (especificidade de 65% e sensibilidade de 67%). Conclusão: Um AOP de 138º parece estar associado com uma MHM positiva no segundo estágio de trabalho de parto.

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.

Fetal bronchopulmonary malformations.

INTRODUCTION: Fetal body tumors are rare, but the ability to diagnose them has improved over recent years. Most masses discovered in the chest results from fetal bronchopulmonary malformations, such as congenital cystic adenomatoid malformation and bronchopulmonary sequestration. Congenital cystic adenomatoid malformation and bronchopulmonary sequestration have a reported incidence of 50% and 33% of all prenatally diagnosed lung lesions, respectively. MATERIAL AND METHODS: Retrospective analysis of the congenital cystic adenomatoid malformation and bronchopulmonary sequestration cases diagnosed or surveilled at our department, between January 2003 and March 2013. Prenatal examination, evolution, management and patient outcome were analyzed. RESULTS: A total of 918 fetal malformations were diagnosed at our hospital, 17 of them representing fetal bronchopulmonary malformations. The majority were diagnosed during the second trimester and stabilized or regressed during the third trimester of pregnancy. The pregnancies and deliveries had no other relevant findings or complications, except in three cases. Nine children required surgery. All of the children are healthy and have a normal development, with regular surveillance by the pediatricians. DISCUSSION: The majority of these fetal lung masses are isolated findings that partially regress during intrauterine life. With adequate postnatal surveillance and eventual surgery the prognosis is good.

Human factors affecting the interpretation of fetal heart rate tracings: an update.

PURPOSE OF REVIEW: Human factors can have an important impact on cardiotocography (CTG) interpretation and management decisions, and therefore may directly affect obstetrical outcomes. RECENT FINDINGS: It has been well demonstrated that there is wide observer disagreement over CTG interpretation, particularly in the evaluation of variability, decelerations, and overall tracing classification. The reasons behind this are still incompletely understood, but poor reproducibility can have a profound impact on the technology's accuracy and on its efficacy. Some scientific societies have recently revised their guidelines for CTG interpretation, but no up-to-date universally accepted recommendation exists. In spite of some approximation between the major guideline sets, important differences still exist between them, and they remain complex and prone to memory decay. Regular training in CTG interpretation appears to result in increased knowledge, better observer agreement, and improved quality of care. Computer analysis has also been developed, but remains heavily dependent on staff to confirm interpretation and to decide clinical management. SUMMARY: An international consensus, comprising simpler and more objective interpretation guidelines, together with regular staff training, and improved decision support systems seem to be the way forward for this technology.

Maternal and neonatal immediate effects of sequential delivery.

OBJECTIVE: To evaluate the immediate maternal and neonatal outcomes associated with sequential instrumental delivery (vacuum plus forceps) compared with the use of one instrument only (forceps or vacuum). STUDY DESIGN: A longitudinal observational study was carried out, including all instrumental deliveries performed in term singleton pregnancies, in vertex presentation, at station level 0 or +1. According to the type of the instruments, the deliveries were divided in three groups: the vacuum group, the forceps group and the sequential group. Immediate maternal and neonatal outcomes were evaluated. RESULTS: A total of 275 instrumental deliveries were performed: 126 (45.5%) vacuum assisted deliveries, 62 (22.6%) forceps assisted deliveries and 87 (31.6%) sequential deliveries. Regarding maternal morbidity, there was a significant difference between the three groups (p < 0.001), with a higher rate of complications in the sequential group. The type of instrument was the only factor associated with significant maternal morbidity. The rate of immediate neonatal morbidity was 4.4% and there was no significant association with the instrument type or with other identifiable factors. CONCLUSION: Sequential delivery is associated with a higher maternal morbidity and it seems not to increase neonatal morbidity.

Prenatal diagnosis of non-immune hydrops fetalis: what do we tell the parents?

OBJECTIVE: The aim of this study is to outline the aetiology and outcome of a series of fetuses with non-immune hydrops (NIH), detected prenatally. The findings are compared with a comprehensive review of recent reports. METHODS: This is a retrospective study reviewing all pregnancies complicated by NIH in the fetus and continued after 20 weeks of pregnancy over a period of 10 years. Outcome was obtained from postmortem reports, discharge summaries, communication with the clinicians or information from the parents. A literature search was also performed to identify all reports on NIH in the last 10 years. RESULTS: Seventy-one fetuses affected by NIH were included in this study. The aetiology of the NIH was identified prenatally in 40 cases. The most common causes of NIH were thoracic disorders, infections and cardiovascular disorders. Forty-four of the 71 (62%) fetuses were live-born. There were 10 neonatal deaths. Of the remaining 34 babies, 17 infants survived without morbidity. CONCLUSION: The survival rate of NIH is at least 48% in this study. Prenatal identification of the cause is possible in 56% of cases. The risk of neurodevelopmental delay in those that survive is 3 of 28 (11%).

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.

Prenatal ultrasonographic diagnosis of abdominal cystic lymphangioma: a case report.

Abdominal lymphangioma is a rare tumor of the lymphatic vessels. A case of an abdominal cystic lymphangioma identified at 22 weeks of gestation is reported. Ultrasonographic monitoring showed a progressive increase of mass size during the gestation. Pregnancy was terminated at 38 weeks and the newborn was submitted to a laparotomy with resection of all cystic structures. At the present time the infant is three years old and is doing well.

Prenatal ultrasonographic diagnosis of vein of Galen aneurysms--report of two cases.

Aneurysms of the vein of Galen (AVG) represent less than 1% of all intracranial arteriovenous malformations. Two cases of prenatal diagnosis made by color Doppler ultrasonography at 32 weeks of gestation are reported. Both cases presented with antenatal mild cardiomegaly and both developed severe cardiac failure in the neonatal period. Embolization was unsuccessful and both infants died. These cases highlight the need for a careful evaluation of the time and mode of delivery; embolization must be performed after a fully informed decision.