Uterine incarceration: a rare diagnosis in non-pregnant women.

Uterine incarceration (UI) is a rare complication in non-pregnant women. A woman in her 50s presented to the emergency department with acute urinary retention and paresis of the right inferior limb. A neurological exam suggested a decrease in the right lower limb strength. On gynaecological exam, the cervix was displaced anteriorly and the cul de sac was obliterated with a pelvic mass. CA 19.9 and CA 125 levels were increased. The MRI of the pelvis confirmed an elongated and anteriorly displaced cervix compressing the urethra and the vesical neck due to a uterine mass. A diagnosis of UI was made and an abdominal hysterectomy with adhesiolysis was suggested as the treatment option. Six months after surgery the patient had no urinary complaints and the neurological exam was normal. UI should be considered in women with urinary and neurological symptoms. A delay in diagnosis may lead to significant morbidity.

Quality of fetal heart rate monitoring with transabdominal fetal ECG during maternal movement in labor: A prospective study.

INTRODUCTION: Transabdominal electrocardiographic (TAfECG) acquisition of fetal heart rate (FHR) signals has recently been introduced into leading commercial cardiotocographic (CTG) monitors. Continuous wireless transmission of signals has raised the possibility of the technology being used during maternal mobilization in labor. This study aims to evaluate signal quality and accuracy of TAfECG acquisition of FHR signals during static and active maternal positions in labor when compared with Doppler signals and with the gold-standard method of fetal scalp electrode (FSE). MATERIAL AND METHODS: A total of 76 women with singleton term pregnancies in the active first stage of labor had simultaneously acquired FHR with TAfECG, Doppler, and FSE. Participants were asked to complete a supervised mobilization scheme, comprising five sequential 10-min periods of lying down, standing, sitting, walking, and rocking on the birthing ball. The three FHR signals were compared, defining signal loss as the percentage of signals under 20 bpm or exceeding 250 bpm and accuracy as the difference with FSE values. Computer analysis was used to quantify variability, accelerations, and decelerations. Static labor positions (lying down, standing, and sitting) were compared with active labor positions (walking and rocking on the birthing ball). RESULTS: Average signal loss was 5.3% with TAfECG (3.2% in static and 7.4% in active positions) and 15.5% with Doppler (8.3% in static and 30.7% in active positions). Average accuracy was 3.5 bpm with TAfECG (1.9 bpm in static and 5.04 bpm in active positions) and 13.9 bpm with Doppler (3.2 bpm in static and 24.7 bpm in active positions). Average variability was similar with TAfECG and FSE in static positions but significantly higher with TAfECG in active positions (23.6 vs. 13.5 bpm, p < 0.001). CONCLUSIONS: In static labor positions, TAfECG provides a low signal loss, similar to that obtained with FSE, and a good signal accuracy, so the technique can be considered reliable when the mother is lying down, standing, or sitting. During maternal movement, TAfECG causes an artificial increase in FHR variability, which can cause false reassurance regarding fetal oxygenation. Doppler signals are unreliable during maternal movements.

Broadening risk factor or disease definition as a driver for overdiagnosis: A narrative review.

Medical overuse-defined as the provision of health services for which potential harms exceed potential benefits-constitutes a paradigm of low-value care and is seen as a threat to the quality of care. Value in healthcare implies a precise definition of disease. However, defining a disease may not be straightforward since clinical data do not show discrete boundaries, calling for some clinical judgment. And, if in time a redefinition of disease is needed, it is important to recognize that it can induce overdiagnosis, the identification of medical conditions that would, otherwise, never cause any significant symptoms or lead to clinical harm. A classic example is the impact of recommendations from professional societies in the late 1990s, lowering the threshold for abnormal total cholesterol from 240 mg/dl to 200 mg/dl. Due to these changes in risk factor definition, literally overnight there were 42 million new cases eligible for treatment in the United States. The same happened with hypertension-using either the 2019 NICE guidelines or the 2018 ESC/ECC guidelines criteria for arterial hypertension, the proportion of people overdiagnosed with hypertension was calculated to be between 14% and 33%. In this review, we will start by discussing resource overuse. We then present the basis for disease definition and its conceptual problems. Finally, we will discuss the impact of changing risk factor/disease definitions in the prevalence of disease and its consequences in overdiagnosis and overtreatment (a problem particularly relevant when definitions are widened to include earlier or milder disease).

Low-grade mucinous appendiceal neoplasm mimicking an ovarian lesion: A case report and review of literature.

BACKGROUND: Appendiceal tumors are rare lesions that may not be easily differentiated from primary ovarian lesions preoperatively, despite the use of advanced diagnostic methods by experienced clinicians. CASE SUMMARY: A 59-year-old G2P2 woman, with chronic pelvic pain, underwent a pelvic ultrasound that revealed an adnexal mass measuring 58 mm × 34 mm × 36 mm, with irregular borders, heterogeneous echogenicity, no color Doppler vascularization and without acoustic shadowing. Normal ovarian tissue was visualized in contact with the lesion, and it was impossible to separate the lesion from the ovary by applying pressure with the ultrasound probe. Ascites, peritoneal metastases or other alterations were not observed. With the international ovarian tumor analysis ADNEX model, the lesion was classified as a malignant tumor (the risk of malignancy was 27.1%, corresponding to Ovarian-Adnexal Reporting Data System category 4). Magnetic resonance imaging confirmed the presence of a right adnexal mass, apparently an ovarian tumor measuring 65 mm × 35 mm, without signs of invasive or metastatic disease. During explorative laparotomy, normal morphology of the internal reproductive organs was noted. A solid mobile lesion involved the entire appendix. Appendectomy was performed. Inspection of the abdominal cavity revealed no signs of malignant dissemination. Histopathologically, the appendiceal lesion corresponded to a completely resected low-grade mucinous appendiceal neoplasm (LAMN). CONCLUSION: The appropriate treatment and team of specialists who should provide health care to patients with seemingly adnexal lesions depend on the nature (benign vs malignant) and origin (gynecological vs nongynecological) of the lesion. Radiologists, gynecologists and other pelvic surgeons should be familiar with the imaging signs of LAMN whose clinical presentation is silent or nonspecific. The assistance of a consultant specializing in intestinal tumors is important support that gynecological surgeons can receive during the operation to offer the patient with intestinal pathology an optimal intervention.

Postpartum lumbosacral radiculopathy: a neuraxial anaesthesia complication or an intrinsic obstetric palsy?

Postpartum peripheral nerve disorders are an uncommon obstetrical complication, with most cases resulting from intrinsic obstetric palsies. We present the case of a full-term nulliparous pregnant 33-year-old woman with a vacuum-assisted vaginal delivery due to a prolonged second stage of labour and occipitoposterior position of the fetal head. For analgesia, a combined spinal-epidural technique was used. Four hours after delivery, the patient experienced a painless asymmetric motor deficit and hypoesthesia in the lower limbs, followed by sphincter disturbance. Emergent MRI was unremarkable. Electromyography showed signs of a bilateral lumbosacral radiculopathy. The patient experienced a gradual recovery over the following 2 months. Although a definitive aetiological diagnosis could not be confirmed, a lumbosacral polyradiculopathy due to intrinsic obstetric complication was considered. The patient presented several risk factors known to be associated with intrinsic obstetric palsies. Obstetricians and anaesthesiologists have an important role in preventing and diagnosing postpartum peripheral nerve disorders.

Cervical mesonephric adenocarcinoma: A case report of a rare gynecological tumor from embryological remains of the female genital tract / Adenocarcinoma mesonéfrico cervical: Relato de caso de um tumor ginecológico raro de restos embriológicos do trato genital feminino

Abstract Introduction Malignant mesonephric tumors are uncommon in the female genital tract, and they are usually located where embryonic remnants of Wolffian ducts are detected, such as the uterine cervix. The information about these tumors, their treatment protocol, and prognosis are scarce. Case report A 60-year-old woman with postmenopausal vaginal bleeding was initially diagnosed with endometrial carcinoma. After suspicion co-testing, the patient underwent a loop electrosurgical excision of the cervix and was eventually diagnosed with mesonephric adenocarcinoma. She was subjected to a radical hysterectomy, which revealed International Federation of Gynecology and Obstetrics (FIGO) IB1 stage, and adjuvant radiotherapy. The follow-up showed no evidence of recurrence after 60 months. Conclusion We present the case of a woman with cervical mesonephric adenocarcinoma. When compared with the literature, this case had the longest clinical follow-up without evidence of recurrence, which reinforces the concept that these tumors are associated with a favorable prognosis if managed according to the guidelines defined for the treatment of patients with cervical adenocarcinomas. Though a rare entity, it should be kept in mind as a differential diagnosis for other cervical cancers.

Cervical Mesonephric Adenocarcinoma: A Case Report of a Rare Gynecological Tumor from Embryological Remains of the Female Genital Tract.

INTRODUCTION: Malignant mesonephric tumors are uncommon in the female genital tract, and they are usually located where embryonic remnants of Wolffian ducts are detected, such as the uterine cervix. The information about these tumors, their treatment protocol, and prognosis are scarce. CASE REPORT: A 60-year-old woman with postmenopausal vaginal bleeding was initially diagnosed with endometrial carcinoma. After suspicion co-testing, the patient underwent a loop electrosurgical excision of the cervix and was eventually diagnosed with mesonephric adenocarcinoma. She was subjected to a radical hysterectomy, which revealed International Federation of Gynecology and Obstetrics (FIGO) IB1 stage, and adjuvant radiotherapy. The follow-up showed no evidence of recurrence after 60 months. CONCLUSION: We present the case of a woman with cervical mesonephric adenocarcinoma. When compared with the literature, this case had the longest clinical follow-up without evidence of recurrence, which reinforces the concept that these tumors are associated with a favorable prognosis if managed according to the guidelines defined for the treatment of patients with cervical adenocarcinomas. Though a rare entity, it should be kept in mind as a differential diagnosis for other cervical cancers.

Genital tuberculosis role in female infertility in Portugal.

INTRODUCTION: Genitourinary tuberculosis is the fourth most common cause of extrapulmonary tuberculosis, although often underestimated by clinicians due to its rare and non-specific symptoms. One of the disease's complications is infertility. Although Portugal is one of the European countries with the highest prevalence of tuberculosis, its impact on Portuguese female fertility is unknown. With this study, we intend to evaluate the prevalence of genital tuberculosis, its presenting symptoms, and pregnancy outcomes in infertile women followed in a Portuguese tertiary hospital. METHODS: Retrospective and descriptive study, performed using an electronic database and consultation of clinical files. Studied population: infertile women followed from 2000 until 2019 at the reproductive unit of a Portuguese tertiary hospital, who underwent endometrial biopsy/curettage in the context of their etiological investigation. The diagnosis of genital tuberculosis was based on histological criteria. RESULTS: Over the 19 years, 2653 endometrial specimens were analyzed. Pathological evaluation was positive for tuberculosis in 19 cases (0.72%). There was a decrease in new diagnoses throughout the observation period. CONCLUSION: Despite being one of the European countries with the highest prevalence of tuberculosis, genital TB does not appear to have a significant impact on the etiology of female infertility in Portugal. Nevertheless, it is a diagnosis to be considered in selected patients.

[Analysis of the Cochrane Review: Antiplatelet Agents for Preventing Pre-Eclampsia and Its Complications. Cochrane Database Syst Rev. 2019;10:CD004659.] / Análise da Revisão Cochrane: O Papel dos Antiagregantes Plaquetários para Prevenir a Pré-Eclâmpsia e as Suas Complicações. Cochrane Database Syst Rev. 2019;10:CD004659.

Pre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia. This Cochrane review aimed to assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing preeclampsia. A systematic review of literature was carried out by searching the following databases up to September 2019: Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. Seventy-seven trials were included, including 40 249 women at risk of developing pre-eclampsia. About 80% of these women were evaluated in nine of the 77 trials included, with eight of these nine trials providing individual data. Interventions were administration of an antiplatelet agent, and comparisons were either placebo or no antiplatelet. The present review provides high-quality evidence that administering low-dose aspirin (50 - 150 mg) to pregnant women led to small-to-moderate benefits, including reductions in the risk of pre-eclampsia, preterm birth, small-for-gestational age fetus, and fetal or neonatal death. Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes.

A pré-eclâmpsia está associada à produção intravascular deficiente de prostaciclina, um vasodilatador, e à produção excessiva de tromboxano, um vasoconstritor e estimulante da agregação plaquetária. Essas observações levaram à hipótese de os antiagregantes plaquetários, em particular o ácido acetilsalicílico, poderem, em dose reduzida, prevenir ou retardar o desenvolvimento da pré-eclâmpsia. Esta revisão da Cochrane teve como objetivo avaliar a eficácia e segurança de antiagregantes plaquetários comparativamente a placebo ou a ausência de tratamento, quando administrados a mulheres em risco de desenvolver pré-eclâmpsia. Foi realizada uma revisão sistemática da literatura até setembro de 2019, através de pesquisa nas seguintes bases de dados: Registo de Ensaios de Gravidez e Parto da Cochrane, ClinicalTrials.gov, Plataforma Internacional de Registo de Ensaios Clínicos da OMS (ICTRP) e listas de referência de estudos recuperados. Foram incluídos 77 ensaios clínicos aleatorizados, incluindo 40 249 mulheres grávidas em risco de desenvolver pré-eclâmpsia. Cerca de 80% destas mulheres foram avaliadas em nove dos 77 ensaios incluídos, sendo que oito destes nove ensaios disponibilizavam dados individuais. O ácido acetilsalicílico foi o antiagregante plaquetário avaliado na maioria dos ensaios, incluindo nos nove ensaios de maior dimensão. A presente revisão concluiu, com qualidade de evidência elevada, que a administração de ácido acetilsalicílico em dose reduzida (50 - 150 mg) a mulheres grávidas está associada a benefícios, considerados de magnitude pequena a moderada, na redução do risco de pré-eclâmpsia, parto prematuro, feto pequeno para a idade gestacional, e morte fetal ou neonatal. A administração de antiagregantes plaquetários a 1000 mulheres resultou em menos 20 gestações com desfechos adversos graves.

Management of pregnancy in case of multiple and giant uterine fibroids.

Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complications. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach.We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians.

National-survey for evaluation of the best screening method of late fetal growth restriction in low risk pregnancy: A prospective study.

OBJECTIVE: To compare knowledge and practices surrounding third trimester screening of fetal growth restriction (FGR) in low risk pregnancies among Portuguese Gynecologists/Obstetricians (GOs) and General Practitioners (GPs). Primary outcome was to compare the proportion of GOs that consider the need of a third trimester ultrasound (estimation of fetal weight) for screening of FGR in low risk pregnancies and the best time to perform it with the corresponding proportion of GPs. STUDY DESIGN: We have conducted a prospective, observational cohort study based on application of surveys to GOs and GPs. Questionnaires were sent by e-mail to physicians and they filled them online. A second reminder e-mail was sent 7 days later. Recruitment was also done personally at scientific meetings. A total of 573 surveys were available for analysis, 298 corresponded to GOs and 275 to GPs. We used χ2 test to compare dichotomous variables and Kruskal-Wallis test for the comparison of ordinal variables. P values <0.05 were considered statistically significant. RESULTS: The vast majority of GOs and GPs (93%) considered that third trimester ultrasound is useful and needed for surveillance of low risk pregnancy. A higher proportion of GOs (38%) selected 35th-37th weeks as the best time to perform the ultrasound compared to GPs (10%) (p < 0.001). GOs (51%) consider that symphysis-fundus distance is a measurement with moderate accuracy for screening of FGR while GPs (61%) attribute a low accuracy (p < 0.001). Fifty percent (50%) of GOs consider that performing a third trimester ultrasound will have no impact on cesarean delivery rate for fetal distress, while 41% of GPs consider that routine ultrasound will contribute to increase this rate (p < 0.001). The majority of GPs (52%) consider that routine ultrasound will contribute to diminish the admission rate to neonatal intensive care unit while GOs revealed a dichotomy with 43% of respondents reporting that it will diminish the rate and 40% that it will have no impact. CONCLUSION: Varied opinions among the clinicians included in our sample reflect the controversy that remains on the best screening of FGR in low risk pregnancies.