Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?

INTRODUCTION: The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries. MATERIAL AND METHODS: Multicentric retrospective cohort study of singleton term breech fetuses delivered vaginally or by elective cesarean section from January 2012 - October 2014. Primary outcomes were maternal and neonatal morbidity or mortality. RESULTS: Sixty five breech fetuses delivered vaginally were compared to 1262 delivered by elective cesarean. Nulliparous women were more common in the elective cesarean group (69.3% vs 24.6%; p < 0.0001). Gestational age at birth was significantly lower in the vaginal delivery group (38 ± 1 weeks vs 39 ± 0.8 weeks; p = 0.0029) as was birth weight (2928 ± 48.4 g vs 3168 ± 11.3 g; p < 0.0001). Apgar scores below seven on the first and fifth minutes were more likely in the vaginal delivery group (1st minute: 18.5% vs 5.9%; p = 0.0006; OR 3.6 [1.9 - 7.0]; 5th minute: 3.1% vs 0.2%; p = 0.0133; OR 20.0 [2.8 - 144.4]), as was fetal trauma (3.1% vs 0.3%: p = 0.031; OR 9.9 [1.8-55.6]). Neither group had cases of fetal acidemia. Admission to the Neonatal Intensive Care Unit, maternal postpartum hemorrhage and the incidence of other obstetric complications were similar between groups. DISCUSSION: Although vaginal breech delivery was associated with lower Apgar scores and higher incidence of fetal trauma, overall rates of such events were low. Admission to the neonatal intensive care unit and maternal outcomes were similar. CONCLUSION: Both delivery routes seem equally valid, neither posing high maternal or neonatal complications' incidence.

Introdução: A melhor via de parto do feto pélvico de termo ainda é controversa. Pretendemos comparar desfechos maternos e neonatais entre partos vaginais e cesarianas de fetos pélvicos de termo. Material e Métodos: Estudo de coorte, multicêntrico e retrospetivo, incluindo gestações de feto único de termo, em apresentação pélvica, que terminaram em parto vaginal ou cesariana eletiva entre janeiro de 2012 e outubro de 2014. Os desfechos primários foram a morbilidade e mortalidade maternas e neonatais. Resultados: Sessenta e cinco partos vaginais foram comparados com 1262 cesarianas eletivas. As nulíparas foram mais frequentes no grupo das cesarianas (69,3% vs 24,6%; p < 0,0001). A idade gestacional foi inferior nos partos vaginais (38 ± 1 semanas vs 39 ± 0,8 semanas; p = 0,0029), verificando-se o mesmo para o peso ao nascer (2928 ± 48,4 g vs 3168 ± 11,3 g; p < 0,0001). Índices de Apgar < 7 foram mais frequentes nos partos vaginais (1º minuto: 18,5% vs 5,9%; p = 0,0006; OR 3,6 [1,9 - 7,0]; 5º minuto: 3,1% vs 0,2%; p = 0,0133; OR 20,0 [2,8 - 144,4]). Verificou-se também uma maior incidência de traumatismo fetal neste grupo (3,1% vs 0,3%; p = 0,031; OR 9,9 [1,8 - 55,6]). Nenhum grupo teve casos de acidemia fetal. As taxas de internamento na unidade de cuidados intensivos neonatais, de hemorragia materna pós-parto ou de outras complicações obstétricas foram idênticas. Discussão: O parto vaginal associou-se a índices de Apgar inferiores e a uma maior incidência de traumatismo fetal, com taxas globalmente baixas. Não se verificaram diferenças nas taxas de internamento neonatal nem nos desfechos maternos. Conclusão: Ambas as vias de parto parecem adequadas, nenhuma condicionando incidências elevadas de complicações maternas ou neonatais.

Glassy cell carcinoma of the cervix and metastasis in episiotomy scar: a case report.

OBJECTIVE: The authors describe the 20th known case of cervical cancer with metastasis in an episiotomy scar, being the first case describing an implant of malignant cells in the episiotomy scar associated with glassy cell carcinoma. MATERIALS AND METHODS: One case report. RESULTS: We describe the case of a 34-year-old woman, with cervical cancer diagnosed 1 month after delivery. Four months later, a radical hysterectomy was performed. During surgery, a nodule at the site of the episiotomy scar was identified and removed. The histologic diagnosis revealed a glassy cell carcinoma of the cervix, with metastasis in the episiotomy scar. After surgery, chemotherapy and radiotherapy were performed. The disease progressed rapidly, and the patient died 9 months after surgery. CONCLUSIONS: The implantation of neoplastic cells in the perineum is a potential risk of vaginal delivery, with a 40% mortality rate. It thus seems advisable to avoid vaginal delivery as much as possible when cervical cancer is diagnosed during pregnancy. Given the rarity, there are no studies on the most effective treatment in such situations.

[Diabetes in pregnancy - postpartum screening]. / Diabetes gestacional - rastreio pós-parto.

INTRODUCTION: One third of women with gestational diabetes mellitus (GDM) will have diabetes or impaired glucose metabolism at postpartum screening. OBJECTIVE: Evaluate the percentage of women submitted postpartum screening and associate the result with maternal history. METHODS: Retrospective investigation of 1013 pregnancies with GDM (2005-2009). We divided the population into two groups according to the result: normal (group 1) and with diabetes or impaired glucose metabolism (group 2). For both groups we evaluated maternal age, body mass index, weight gain during pregnancy, need for insulin therapy, risk factors for GDM, and newborn weight. RESULTS: Postpartum screening was achieved in 76.8% of women (n=778). The test was considered normal (group 1) in 628 women (80.7%) and modified (group 2) in 150 women (19.3%). Group 2 had older women (median age 34 vs. 33 years; p-value 0.013), higher body mass index (28.5 vs. 25.8kg/cm2; p-value 0.000), more women with diabetes mellitus family history in first degree (50.3% vs. 39.9%; p-value 0.026) and prior personal history of macrosomia (12.1% vs 5.4%; p-value 0.003). Earlier diagnosis of GDM was also made in this group (27 vs. 31 weeks; p-value 0.000) and a higher percentage had made insulin therapy (41% vs. 15%; p-value 0.000), having started earlier (28 vs 30 weeks; p-value 0.010). There was a higher percentage of multiparous pregnant in group 2 (64% vs 49.4%; p-value 0.001) and a larger number of cases of newborns large for gestational age (17.1% vs 8.3%; p-value 0.001). Personal history of GDM and weight gain during pregnancy was similar in both groups. CONCLUSIONS: Women who test abnormal in postpartum screening are usually older, heavier, multiparous, with a family related to DM patients and prior personal history of macrosomia. GDM diagnosis is made earlier in pregnancy, more often they need insulin therapy started ealier and there was a higher number of newborns large for gestational age.

Calcinose cútis distrófica universal associada a lúpus eritematoso sistêmico: um caso exuberante / Calcinosis cutis universalis associated with systemic lupus erythematosus: an exuberant case

Calcinose cutânea é uma doença incomum, de fisiopatologia incerta e, muitas vezes, incapacitante. Caracteriza-se pela deposição de sais de cálcio na pele ou tecido subcutâneo. É classificada em quatro subtipos: metastática, distrófica, idiopática e iatrogênica. Pode ser vista em várias doenças sistêmicas como hiperparatireoidismo e hipervitaminose D, ocorrendo com maior frequência na dermatomiosite, esclerodermia e síndromes overlap, sendo uma complicação infrequente no lúpus eritematoso sistêmico. O manejo das complicações secundárias, assim como o sucesso terapêutico, constituem desafios constantes no seguimento destes casos.

Calcinosis cutis is an uncommon disease of unclear pathophysiology that is often disabling. It is characterized by the formation of calcium deposits in the skin or subcutaneous tissue. It is classified into four subtypes: dystrophic, metastatic, idiopathic or iatrogenic. It may be seen in a variety of systemic diseases such as hyperparathyroidism and hypervitaminosis D, but is most commonly found in dermatomyositis, scleroderma and overlap syndromes and is a rare complication of systemic lupus erythematosus. The management of secondary complications and the success of therapy are constant challenges in the follow-up of these cases.

Calcinosis cutis universalis associated with systemic lupus erythematosus: an exuberant case.

Calcinosis cutis is an uncommon disease of unclear pathophysiology that is often disabling. It is characterized by the formation of calcium deposits in the skin or subcutaneous tissue. It is classified into four subtypes: dystrophic, metastatic, idiopathic or iatrogenic. It may be seen in a variety of systemic diseases such as hyperparathyroidism and hypervitaminosis D, but is most commonly found in dermatomyositis, scleroderma and overlap syndromes and is a rare complication of systemic lupus erythematosus. The management of secondary complications and the success of therapy are constant challenges in the follow-up of these cases.

Cutaneous metastasis of gastric adenocarcinoma: an exuberant and unusual clinical presentation.

There are different types of skin changes associated with internal malignancy. One type is the skin involvement as a result of cutaneous metastasis from an internal tumor. The skin is an uncommon site for distant metastasis; when it is present the most common sources are breast, lung, and colon. Metastasis generally occurs after an internal malignancy had been discovered and signifies disseminated disease with a poor prognosis. We report an exuberant and rare case of cutaneous metastasis from gastric adenocarcinoma as the first sign of this serious visceral cancer.