Avaliação ecográfica do crescimento fetal no final do 3º trimestre da gravidez de baixo risco

A avaliação da estimativa do peso fetal (EPF) durante o exame ecográfico do terceiro trimestre na gravidez de baixo risco, e considerada o método mais eficaz de diagnostico de restrição do crescimento fetal (RCF), permitindo uma adequada vigilância e programação do parto. Contudo, não existe consenso relativamente a necessidade de um exame ecográfico de rotina, durante o terceiro trimestre da gravidez de baixo risco, com o objetivo de rastreio de RCF, nem de qual será a melhor idade gestacional para a sua realização. Até a data, a realização deste exame não demonstrou vantagens em termos de desfechos perinatais. Não obstante, os casos de RCF tardias não diagnosticados anteparto representam uma proporção significativa de mortes fetais no termo e estão associados a um maior risco de desfechos neonatais adversos, comparativamente aos casos de RCF diagnosticados durante a gravidez. O objetivo global desta tese foi a investigação quanto ao melhor método de rastreio de RCF tardia, em gravidas de baixo risco, incluindo-se para tal cinco projetos. O projeto I consistiu num estudo retrospetivo em que foi comparada a via de parto e a taxa de admissão de recém-nascidos nas unidades de cuidados intensivos neonatais, entre aqueles com peso adequado para a idade gestacional e os leves para a idade gestacional, de gestações de termo e de baixo risco. Um total de 1429 gravidas foi incluído, com uma taxa de 11% de leves para a idade gestacional (LIG), definidos como recém-nascidos ³ 37 semanas com peso ao nascimento < percentil 10. Os LIG associaram-se a maior taxa de cesariana por suspeita de hipoxia fetal intraparto (18/151 vs 8/1202, p < 0,001) e maior taxa de admissão nas unidades de cuidados intensivos neonatais (16/151 vs 18/1202, p < 0,001). Entre os LIG, verificamos que os que foram diagnosticados por ecografia anteparto apresentaram menor taxa de parto instrumental/cesariana por suspeita de hipoxia fetal intraparto comparativamente com o grupo de LIG que não foram diagnosticados anteparto (3/31 vs 39/120, p = 0,01). O projeto II correspondeu a um estudo prospetivo que avaliou a reprodutibilidade das biometrias fetais ecográficas (diâmetro biparietal, perímetro cefálico, perímetro abdominal e comprimento do fémur) realizadas as 35-37 semanas de gestação. Um total de 197 gravidas foi incluído e cada uma foi submetida a três avaliações ecográficas sucessivas, uma por um ecografista e duas por um outro ecografista, correspondendo a um total de 591 avaliações ecográficas. Registaram-se coeficientes de correlação intra e inter-observador muito elevados para todas as medidas avaliadas (todos com valores superiores a 0,85), demonstrando-se elevada reprodutibilidade intra e inter-observador da ecografia do terceiro trimestre realizada as 35-37 semanas de gestação. O projeto III foi um estudo prospetivo observacional que teve como objetivo comparar o conhecimento e pratica clinica entre os Ginecologistas-Obstetras (GOs) e os médicos de Medicina Geral e Familiar (MGF) portugueses relativamente ao rastreio de RCF em gravidas de baixo risco, através da aplicação de questionários, tendo-se conseguido um total de 573 respostas. Verificamos que uma maior proporção de GOs (38%) selecionaram a ecografia as 35-37 semanas como o melhor momento no terceiro trimestre para rastreio de RCF, comparativamente com a proporção de médicos de MFG (10%) (p < 0,001). O projeto IV consistiu num estudo prospetivo aleatorizado que comparou a acuidade diagnostica e os desfechos perinatais entre um grupo de controlo, que realizou apenas a ecografia de rotina no terceiro trimestre, as 30-33 semanas de gestação, e um grupo de estudo que realizou uma ecografia adicional as 35-37 semanas, incluindo-se um total de 1093 gravidas de baixo risco. A ecografia realizada as 35-37 semanas registou uma acuidade diagnostica global para rastreio de RCF de 94%. O coeficiente de correlação de Spearman foi superior entre o percentil da EPF as 35-37 semanas e o percentil do peso ao nascimento (ρ = 0,75), comparativamente com o coeficiente de correlação entre o percentil da EPF as 30-33 semanas e o percentil do peso ao nascimento (ρ = 0,44). O grupo de estudo registou também melhores desfechos perinatais, nomeadamente uma menor taxa de partos vaginais instrumentados por suspeita de hipoxia fetal intraparto (24,4% vs 39,3%, p = 0,005) e menor taxa de cesarianas por suspeita de hipoxia fetal intraparto (16,8% vs 38,8%, p < 0,001), comparativamente com o grupo de controlo. O projeto V constou de um estudo prospetivo com o objetivo de investigar se a neurossonografia permite detetar alterações da substância branca e cinzenta na RCF. Com um total de 318 fetos submetidos ao estudo neurossonográfico, foi possível demonstrar que as RCF tardias apresentam diferenças em termos de desenvolvimento cortical e do corpo caloso, comparativamente com os casos de controlo, sugerindo que a neurossonografia permite demonstrar algumas diferenças de reorganização cerebral na RCF. Em conclusão, um exame ecográfico mais tardio durante o terceiro trimestre (35-37 semanas de gestação) tem precisão e maior correlação com o percentil do peso ao nascimento do que um exame mais precoce no terceiro trimestre, podendo ainda contribuir para diminuir desfechos perinatais adversos. As diferenças nos padrões neurossonográficos entre fetos com crescimento adequado para a idade gestacional e com RCF reforçam o conceito de que uma abordagem combinada que inclua biometrias fetais, bem como outros marcadores clínicos, biológicos e/ou imagiológicos, pode contribuir para otimizar o rastreio de RCF e os desfechos perinatais

Endometriosis and cardiovascular disease: a systematic review and meta-analysis

© 2023 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/Objectives: Endometriosis is a benign, estrogen-dependent, chronic inflammatory disease and is the commonest cause of chronic pelvic pain in younger women. Cardiovascular disease is the main cause of death worldwide. Because the relationship between endometriosis and CV disease is not well established, we performed a systematic review of longitudinal studies that assessed the occurrence of cardiovascular events in women with endometriosis compared to those without endometriosis. Study design: Systematic review with meta-analysis of longitudinal cohort/nested case-control studies with endometriosis patients and controls. A search was conducted of the MEDLINE, CENTRAL, and Embase databases from inception to November 2022. Random-effects meta-analysis was performed to estimate pooled hazard ratios (HR) and 95 % confidence intervals (95%CI). Main outcome measure: Cardiovascular outcomes such as ischemic heart disease and cerebrovascular disease. Results: Six cohort studies were included, with a total of 254,929 participants. Meta-analysis showed that endometriosis was associated with a significantly increased risk of ischemic heart disease (HR 1.50, 95%CI 1.37–1.65; I 2 = 0 %) and cerebrovascular disease (HR 1.17, 95%CI 1.07–1.29; I 2 = 0 %). The one study that examined the relationship between cardiovascular mortality and endometriosis found a decreased risk in women with endometriosis relative to women without endometriosis (HR 0.55 (95%CI 0.47–0.65)). Conclusions: Endometriosis is associated with a significantly increased risk of cardiovascular disease, namely ischemic heart disease and cerebrovascular disease. Further studies are required to determine if endometriosis and/or its treatments are risk factors (particularly for cardiovascular mortality), and whether preventive measures could reduce the burden of cardiovascular disease in women with endometriosis. Study protocol registered at PROSPERO: CRD42022298830.info:eu-repo/semantics/publishedVersio

Restless legs syndrome in pregnancy : a frequent underdiagnosed disorder

Copyright © Ordem dos Médicos 2014We realize that the restless legs syndrome (RLS) is underdiagnosed in pregnancy, despite being an important cause of insomnia and impaired sleep. Our objective is to report the case of a pregnant woman with RLS surveilled at our Department and briefly review the main points of this disorder, to alert obstetricians, neurologists and family doctors to this entity.info:eu-repo/semantics/publishedVersio

A Randomized Trial

Policiano, C., Mendes, J. M., Fonseca, A., Barros, J., Vargas, S., Cal, M., Martins, I., Carvalho, C., Martins, D., Clode, N., & Graca, L. M. (2023). Routine Ultrasound at 30th–33rd weeks versus 30th–33rd and 35th–37th weeks in Low-Risk Pregnancies: A Randomized Trial. Fetal Diagnosis and Therapy , 49(9-10), 425–433. https://doi.org/10.1159/000527112 --- Funding Information: This work was supported by a Research Grant from Fundação para a Ciência e Tecnologia (FCT)-SFRH/SINTD/92997/2013. The funder was not involved in the study design, collection, analysis, data interpretation, or in the writing of this report. The trial was registered in ClinicalTrials.gov with the identification number: NCT03200665.INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.authorsversionpublishe

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

© 2019 Elsevier B.V. All rights reserved.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.This work was supported by a Research Grant from Fundação para a Ciência e Tecnologia (FCT) - SFRH/SINTD/92997/2013.info:eu-repo/semantics/publishedVersio

Small-for-gestational-age babies of low-risk term pregnancies : does antenatal detection matter?

© 2017 Informa UK Limited, trading as Taylor & Francis Group.Objectives: To compare delivery route and admission rate to neonatal intensive care unit between small- and appropriate-for-gestational-age babies among low-risk term pregnancies. Methods: A retrospective study was conducted using the database of deliveries in 2014 at a tertiary hospital. Babies delivered at ≥37 weeks with birthweight 90th centile were considered large-for-gestational-age. Fetal weight estimation at 30-33 weeks ultrasound <10th centile was considered antenatal detection of SGA. Results: Among 1429 low-risk term pregnancies, 11% (151/1429) had SGA babies and 5% (75/1429) had large-for-gestational-age. SGA babies were associated with higher rate of cesarean sections for nonreassuring fetal status (18/151 versus 8/1202, p < .001) and higher rate of admissions to neonatal intensive care unit (16/151 versus 18/1202, p < .001) compared to appropriate-for-gestational-age. Within SGA group, antepartum detected fetuses were associated with lower rate of operative deliveries for nonreassuring fetal status than undetected group (3/31 versus 39/120, p = .01) Conclusions: In our series, women with SGA term babies were associated with more adverse obstetric and neonatal outcome than appropriate-for-gestational age, especially among those undetected prenatally.This work was supported by a Research Grant from Fundação para a Ciência e Tecnologia (FCT) – SFRH/SINTD/ 92997/2013.info:eu-repo/semantics/publishedVersio

Altered cortical development in fetuses with isolated nonsevere ventriculomegaly assessed by neurosonography

OBJECTIVES: To perform a comprehensive assessment of cortical development in fetuses with isolated nonsevere ventriculomegaly (INSVM) by neurosonography. METHODS: We prospectively included 40 fetuses with INSVM and 40 controls. INSVM was defined as atrial width between 10.0 and 14.9 mm without associated malformation, infection, or chromosomal abnormality. Cortical development was assessed by neurosonography at 26 and 30 weeks of gestation measuring depth of selected sulci and applying a maturation scale from 0 (no appearance) to 5 (maximally developed) of main sulci and areas. RESULTS: INSVM showed underdeveloped calcarine and parieto-occipital sulci. In addition, significant delayed maturation pattern was also observed in regions distant to ventricular system including Insula depth (controls 30.8 mm [SD 1.7] vs INSVM 31.7 mm [1.8]; P = .04), Sylvian fissure grading (>2 at 26 weeks: controls 87.5% vs INSVM 50%, P = .01), mesial area grading (>2 at 30 weeks: controls 95% vs INSVM 62.5%; P = .03), and cingulate sulcus grading (>2 at 30 weeks: controls 100% vs INSVM 80.5%; P = .01). CONCLUSIONS: Fetuses with INSVM showed underdeveloped cortical maturation including also regions, where effect of ventricular dilatation is unlikely. These results suggest that in a proportion of fetuses with INSVM, ventricular dilation might be related with altered cortical architecture

The National Student Survey: validation in Portuguese medical students

The UK National Student Survey (NSS) is a sound and widely used instrument for assessing students’ academic experiences. We aimed to translate the NSS for Portuguese students and to validate the instrument in a sample of medical undergraduates. The research team translated and adapted the NSS for Portuguese students (NSS-P). The survey was administered on an online platform to 1,256 final-year students at eight Portuguese medical schools. A total of 329 medical students (69.9% female) replied to the NSS-P, a response rate of 26.2%. Confirmatory factor analysis showed that the original six-factor structure had an adequate fit to the data. Adequate internal consistency was observed for all the subscales. Medium to large correlations were found among all the subscale scores and between the subscale scores and the students’ overall satisfaction. Multiple regression showed that the scores on the Teaching, Organization and Management and Personal Development subscales significantly predicted the students’ overall satisfaction. Approximately 64% of the students reported being satisfied with the quality of their courses. Significant differences among the medical schools in their NSS-P scores were found. The NSS-P is a valid and reliable measure for assessing medical students’ perceptions of academic quality