Ineffective Pregnancy Prevention During Adolescence: Assisting Healthcare Providers in Portugal With Individualized Risk Assessment.

In this study, we describe the relative contributions of and interactions between individual risk factors associated with ineffective pregnancy prevention among female adolescents in Portugal. Our sample consisted of 856 sexually experienced female adolescents (10-19 years) who did not intend to become pregnant. Of these, 379 were pregnant, and the residual (477) had never been pregnant. We used classification tree analysis to describe the interplay among a set of established sociodemographic, familial, reproductive, and relationship factors as predictors of ineffective pregnancy prevention. The tree model showed good predictive properties. Seven profiles predicted one-half to all the cases of ineffective pregnancy prevention. Ineffective pregnancy prevention was predicted by adolescents' grade level and different combinations of variables, specifically female age, age at the time of first sexual intercourse, religious beliefs, place of residence, maternal pregnancy before age 20, household structure in childhood, and partner's age difference. According to our findings, limiting assessments to the cumulative presence of risk factors may be insufficient to accurately identify adolescents at elevated risk of unwanted pregnancy, as the impact of any given risk factor may vary according to other factors. Our findings may contribute to the development of a risk assessment tool that may support healthcare providers' efforts to provide individualized risk assessment for adolescent patients and, thus, to better support pregnancy prevention.

"Referendum on Sunday, working group on Monday": A success story of implementing abortion services after legalization in Portugal.

A 2007 referendum legalized abortion in Portugal. Physicians played an important role advocating for legal reform and providing services thereafter. Implementers relied on a strong public health system with many gynecologists who required minimal training, and took decisions that allowed for rapid implementation. First, they emphasized medical abortion and integrated abortion into existing hospital obstetrics and gynecologic services, where eventual complications could be managed. They also offered immediate postabortion contraception, helping prevent criticism from abortion opponents who feared women would obtain multiple repeat abortions. Finally, they established referral networks guaranteeing access despite conscientious objection. Media campaigns were not needed as Portuguese women had good access to information. Portugal's success is largely due to key facilitators within a working group established by the Ministry of Health to implement the new law. Remaining challenges are the lack of choice between medical and surgical abortion, and some regions with relatively difficult geographic access to services.

Sociodemographic, sexual, reproductive and relationship characteristics of adolescents having an abortion in Portugal: a homogeneous or a heterogeneous group?

OBJECTIVES: The aims of the study were to describe the sociodemographic, sexual, reproductive and relational characteristics of adolescents having an abortion in Portugal and to explore the differences between three adolescent age groups. METHODS: We recruited a nationally representative sample of 224 adolescents (<16 years, n = 18; 16-17 years, n = 103; 18-19 years, n = 103) who had an abortion. Data were collected from 16 health care services that provide abortion. RESULTS: The adolescents were predominantly single, were from non-nuclear families, had low-socioeconomic status and were students. Mean age at first sexual intercourse was 15 years and mean gynaecological age was 5 years. Most had had multiple sexual partners, and for most it was their first pregnancy. At conception, the majority were involved in a long-term romantic relationship, were using contraception but did not identify the contraceptive failure that led to the pregnancy. Significant age group differences were found. Compared with the younger age groups, the 18-19 year age group was more frequently married or living with a partner, had finished school, had attained a higher educational level (as had their partner), intended to go to university, and had a greater number of sexual partners. Compared with the other groups, those under 16 years of age reported earlier age at menarche and at first sexual intercourse, and had a lower gynaecological age. CONCLUSIONS: Our study characterises the life contexts of Portuguese adolescents who had an abortion. It highlights the need to recognise the heterogeneity of this group according to age. The findings have important implications for the development of age-appropriate guidelines to prevent unplanned pregnancy.

Lowered national cesarean section rates after a concerted action.

OBJECTIVE: To evaluate national cesarean section (CS) rates and other obstetric indicators after a concerted action to reduce CS rates was undertaken in Portugal from 2010 onwards. This action was based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding. DESIGN: Retrospective observational population-based study. SETTING: Portugal. POPULATION: Births occurring in Portugal between 2000 and 2014. METHODS: Governmental sources were used to obtain data on national CS, perinatal and maternal mortality rates. Rates of instrumental vaginal delivery, vaginal birth after cesarean (VBAC), hypoxia-related complications and perineal lacerations were retrieved for state-owned hospitals. MAIN OUTCOME MEASURES: CS, perinatal and maternal mortality, instrumental vaginal delivery, VBAC, hypoxia-related complications and perineal lacerations. RESULTS: After a continuous rise between 2000 and 2009, national CS rates declined significantly over the following 5 years (36.6% vs. 33.1%, time trend p ≤ 0.001). Perinatal mortality maintained a downward trend during this period, while maternal mortality remained unchanged. Rates of instrumental vaginal delivery, VBAC and perineal lacerations increased, while the incidence of hypoxia-related complications decreased. CONCLUSIONS: A concerted action based on the transmission of information and training of healthcare professionals, together with the inclusion of CS rates as a criterion for hospital funding, was followed by a significant reduction in national CS rates, as well as an improvement in most related obstetric indicators. There may be an association between the reported intervention and the observed changes.

[Relational and reproductive trajectories leading to adolescent pregnancy in Portugal: a national and regional characterization]. / Trajetórias Relacionais e Reprodutivas Conducentes à Gravidez na Adolescência: a Realidade Nacional e Regional Portuguesa.

INTRODUCTION: The current study aimed to describe the relational and reproductive trajectories leading to adolescent pregnancy in Portugal, and to explore whether there were differences in this process according to adolescents' place of residence. MATERIAL AND METHODS: Data were collected between 2008 and 2013 in 42 public health services using a self-report questionnaire developed by the researchers. The sample consisted of a nationally representative group of pregnant adolescents (n = 459). RESULTS: Regardless of having had one (59.91%) or multiple sexual partners (40.09%), the majority of adolescents became pregnant in a romantic relationship, using contraception at the time of the conception and knowing the contraceptive failure which led to pregnancy (39.22%). In some regions other trajectories were highly prevalent, reflecting options such as planning the pregnancy (Alentejo Region/ Azores Islands), not using contraception (Centro Region/Madeira Islands) or using it incorrectly, without identifying the contraceptive failure (Madeira Islands). On average, romantic relationships were longer than 19 months and adolescents' partners were older than themselves (> 4 years) and no longer in school (75.16%); these results were particularly significant when the pregnancy was planned. DISCUSSION: The knowledge gained in this study shows that prevention efforts must be targeted according to the adolescents' needs in each region and should include high-risk male groups. CONCLUSION: Our results may enable more efficient health policies to prevent adolescent pregnancy in different country regions and support educators and health care providers on sexual education and family planning efforts.

Introdução: Este estudo pretendeu caracterizar as trajetórias relacionais e reprodutivas conducentes à gravidez na adolescência em Portugal, explorando a existência de especificidades regionais.Material e Métodos: O estudo decorreu entre 2008 e 2013 em 42 serviços de saúde públicos. A amostra, nacionalmente representativa, incluiu 459 grávidas com idades entre os 12 e os 19 anos. Os dados foram obtidos por autorrelato, através de uma ficha de caracterização construída para o efeito.Resultados: Independentemente de terem tido um (59,91%) ou múltiplos parceiros sexuais (40,09%), as adolescentes engravidaram de forma mais frequente numa relação de namoro, utilizando contraceção à data da conceção e tendo identificado a falha contracetiva que esteve na origem da gravidez (39,22%). A nível regional, outras trajetórias surgiram com elevada prevalência, refletindo opções como a decisão de engravidar (Alentejo/Açores), a não utilização de contraceção (Centro/Madeira) ou a sua utilização ineficaz sem que a falha contracetiva fosse identificada (Madeira). As relações de namoro revelaram-se maioritariamente duradouras (> 19 meses), com homens mais velhos (> 4 anos) e fora do sistema de ensino (75,16%); estes resultados foram particularmente expressivos quando a gravidez foi planeada.Discussão: O conhecimento gerado por este estudo reflete a necessidade de investir em abordagens preventivas que atendam às necessidades específicas das jovens de cada região e integrem a população masculina de maior risco.Conclusão: Os nossos resultados podem contribuir para o delineamento de políticas de saúde mais eficazes e para uma atuação multidisciplinar mais informada ao nível da educação sexual e do planeamento familiar nas diferentes regiões do país.

Knowledge-attitude-practice survey among Portuguese gynaecologists regarding combined hormonal contraceptives methods.

ABSTRACT Objectives To evaluate knowledge, attitude and practices of Portuguese gynaecologists regarding combined hormonal contraceptives. Methods A cross-sectional survey was conducted among 303 gynaecologists. Results Ninety percent of the gynaecologists considered that deciding on contraceptive methods is a process wherein the woman has her say. Efficacy, safety and the woman's preference were the major factors influencing gynaecologists, while efficacy, tolerability and ease of use were the major factors perceived by the specialists to influence the women's choice. Gynaecologists believed that only 2% of women taking the pill were 100% compliant compared to 48% of those using the patch and 75% of those using the ring. The lower risk of omission was the strong point for the latter methods. Side effects were the main reason to change to another method. Vaginal manipulation was the most difficult topic to discuss. Conclusions Most gynaecologists decided with the woman on the contraceptive method. The main reasons for the gynaecologist's recommendation of a given contraceptive method and the women's choice were different. Counselling implies an open discussion and topics related to sexuality were considered difficult to discuss. Improving communication skills and understanding women's requirements are critical for contraceptive counselling.

Impact of a women's counselling programme on combined hormonal contraception in Portugal--the IMAGINE Study.

BACKGROUND: The aim of this health education project was to measure the impact of counselling about combined hormonal contraceptive (CHC) methods on the subsequent choice of method by Portuguese women. METHOD: This was a multi-centre study with a representative population, at the national and regional levels, of 2951 Portuguese women≥16 years of age visiting the gynaecologist. Counselling on available CHC methods was provided using a single leaflet, and their CHC choice was assessed before and after counselling. RESULTS: A combined oral contraceptive (COC) was the method preferred by the majority of the women prior to counselling. After counselling, 35% of women who initially had chosen the pill, switched to either the vaginal ring or the transdermal patch, and the difference was statistically significant. Ease of use was the major reason for choosing the COC, while a lower probability of omission was the reason for choosing the vaginal ring and the patch. CONCLUSIONS: The implementation of a counselling programme significantly affected contraceptive choices leading in a number of cases to the selection of alternatives better suited to women's lifestyle. Age and educational level are socio-demographic factors which play an important role.

Acute myocardial infarction in the puerperium.

The authors describe the case of a forty-two-year-old patient with acute myocardial infarction (MI) on the third day of puerperium, who underwent direct angioplasty. The authors review the main physiological cardiovascular and hemostatic changes in pregnancy, which are usually well tolerated but which increase the probability of cardiovascular events when risk factors or previous cardiac disease are associated. Blood volume and cardiac output increase by around 50% during pregnancy, hemoglobin concentration falls, and reduced peripheral vascular resistance leads to a fall in arterial blood pressure during the first half of pregnancy. End-diastolic pressure, stroke volume and cardiac output increase in the immediate puerperium, and cardiovascular risk is highest in the perinatal period. The incidence of MI during pregnancy and puerperium is low; however, it is on the increase due to the growing number of pregnancies in women close to the end of their reproductive age.

Etonogestrel implant in women with diabetes mellitus.

OBJECTIVES: To evaluate the effect of etonogestrel implant on the control of the carbohydrate and lipid metabolism and on the progression of vascular complications in diabetic women treated with insulin, and to assess the acceptability of this modality of contraception in these patients. METHODS: Prospective-observational study of 23 women with insulin-treated diabetes. Clinical and metabolic evaluation was performed before and at 3, 6, 12, and 24 months after implant insertion. Changes from baseline were compared using the mixed effects models or Wilcoxon matched-pairs signed-rank tests. RESULTS: There were no significant changes in BMI, in daily insulin requirement and in mean HbA1c. There was a significant reduction of total serum cholesterol (TC) at 6 and 12 months, of triglyceride levels at 6, 12 and 24 months, and of high-density lipoprotein cholesterol (HDL-C) at 6, 12 and 24 months. Neither the low-density lipoprotein (LDL) levels nor the HDL/TC ratio changed. Albuminuria decreased significantly at 12 and 24 months. No deterioration of the retina was observed over the study period. Amenorrhoea and infrequent bleeding were the most common menstrual bleeding patterns. One woman discontinued the method due to frequent bleeding. CONCLUSION: We found no evidence of impaired control of the carbohydrate and lipid metabolism or aggravation of vascular lesions during the two years an etonogestrel implant was used by diabetic women.

[Prophylaxis of RhD isoimmunization: a proposal of management]. / Profilaxia da isoimunização RhD: uma proposta de protocolo.

Isoimmunisation RhD has an important perinatal morbidity and mortality. Since prophylaxis was introduced in the sixties, the incidence of haemolytic disease of the newborn has decreased. When administred in due time and in the right dosage anti-D immunoglobulin can prevent sensibilization. Nevertheless new cases continue to occur, underlying the need for an urgent improvement of our conduct. The purpose of this review is to provide an overview of the pathology of RhD isoimmunization and of aspects involved in its prophylaxis.