Vinte Anos de Actividade Cientifica

O dinamismo e capacidade de actualização de uma equipa médica traduzem-se na actividade científica de uma unidade de saúde. Essa actividade constitui por isso um meio de avaliar o seu desempenho. Objectivo: Foi nosso objectivo avaliar a actividade científica médica desenvolvida na unidade de cuidados intensivos neonatais (UCIN) do Hospital de Dona Estefania desde a abertura, em Abril de 1983, ate a comemoração dos seus 20 anos, em Abril de 2003. Material e Métodos: Os dados foram coligidos a partir dos curricula dos elementos da equipa, dos arquivos da unidade, da publicação do Anuário entre 1993 e 2001 e da memória de alguns elementos. Foram englobados os seguintes itens: presidência e moderação de conferências, palestras e mesas redondas; conferências, palestras e comunicações livres; trabalhos publicados; participação em estudos mu1ticêntricos nacionais e internacionais; estudos prospectivos desenvolvidos pela própria unidade; trabalhos indexados em Medline e citações; colaboração em teses de doutoramento e mestrado; participação em conselhos científicos, editorais ou redactoriais de revistas cientificas; e, finalmente, a actividade desenvolvida no âmbito de corpos directivos de sociedades científicas. Excluiram-se as apresentações em reuniões da unidade, do serviço ou outras reuniões de âmbito estritamente hospitalar e as palestras proferidas no âmbito do ensino pré-graduado. O número de médicos/ano foi calculado com base no número de anos durante o qual cada elemento integrou a equipa, o número total de elementos que dela já fizeram parte e os 20 anos da unidade. Resultados: A média do número de medicos na UCIN foi de 9 por ano. Contabilizaram-se 123 moderações de mesa - 98 nacionais e 25 internacionais (média de 6 por ano; O,7/médico/ano); 487 conferências, palestras e comunicações 1ivres - 368 nacionais e 119 internacionais (média de 25 intervenções/ano; 2,7 intervenções/médico/ano); 221 publicações (média 11 publicações/ano: 1,2 trabalhos/médico/ano). Os anos de encerramento da maternidade são os de menor número de comunicações livres. A Unidade participou em 20 trabalhos prospectivos nacionais, em 14 estudos multicêntricos, dos quais 5 internacionais, e em 5 teses de mestrado ou doutoramento. Onze trabalhos estão indexados em Medline, encontraram-se 21 citações e foram atribuidos prémios a 23 trabalhos. Houve 10 participações em corpos directivos de sociedades cientificas, 1 das quais internacional; 15 participações em corpos redactoriais e editoriais de revistas científicas, 3 das quais internacionais e organização de 64 reuniões cientificas, 5 das quais internacionais. Discussão: Não havendo termo de comparação: é difícil dizer se a actividade da UCIN foi aceitável. Apesar do esforço que sabemos ter sido desenvolvido e da preocupação que sempre orientou os chefes, a revisão parece somar pouco trabalho, nomeadamente no que respeita a publicações. A UCIN deve melhorar e deve induzir a melhoria do hospital. Por isso se fazem algumas propostas: estágios de internos em serviços idóneos com os quais se estabeleçaa intercâmbio cientifico; publicação em revistas indexadas; participação em estudos multicêntricos nacionais e internacionais; maior recurso a bolsas de investigação. A promoção da investigação passa pela definição de objectivos por períodos definidos, por grupos profissionais e por áreas de interesse, pela avaliação da concretização desses objectivos e pelo envolvimemo activo da instituição. Para isso será fundamental o papel do Departamento de Investigação em Pediatria recentemente criado.

Pediatria do Neurodesenvolvimento. Levantamento Nacional de Recursos e Necessidades

As perturbações do neurodesenvolvimento são das patologias crónicas mais frequentes da infância e com tendência a aumentar nas sociedades modernas. Têm na grande maioria dos casos um percurso crónico e com limitação da aprendizagem necessária para a integração na sociedade de um modo autónomo. A Sociedade de Pediatria do Neurodesenvolvimento da Sociedade Portuguesa de Pediatria procedeu em 2008 e 2009 ao levantamento de recursos, movimento e necessidades na área assistencial do neurodesenvolvimento no universo de 49 hospitais portugueses com Pediatria, referente a 31 de Dezembro de 2007. Responderam 42 (85.7%) hospitais. O número total de consultas de desenvolvimento representou 10.7% das de Pediatria, e foi- -lhe imputada uma mediana de tempo de 20 horas por semana. Dedicavam-se ao desenvolvimento 82 pediatras, mas mais de dois terços só o fazia a tempo parcial. Outros profissionais (fisiatras, psicólogos, terapeutas da fala, terapeutas ocupacionais, fisioterapeutas, docentes e técnicos de Serviço Social) faziam parte das equipas do desenvolvimento, mas em menor número que os pediatras, e de igual modo só raramente a tempo completo. Aguardava por consulta de desenvolvimento uma mediana de 185 crianças, e o tempo de espera variou entre um e 18 meses(mediana de seis). No seu conjunto os hospitais a curto prazo recrutariam 34 Pediatras para se dedicarem à área do neurodesenvolvimento,metade em regime de tempo completo. Dos outros profissionais requisitados [psicólogos (21), terapeutas da fala (20), docentes (20), terapeutas ocupacionais (14), fisioterapeutas (8) e técnicos do Serviço Social (6)], solicitavam-nos a tempo inteiro. Concluí-se que o movimento assistencial específico desta área no contexto global da Pediatria representa já um número significativo de consultas. Ainda assim, a resposta na área do neurodesenvolvimento revelou-se insuficiente e as equipas não funcionavam na generalidade em trabalho multidisciplinar. Contudo, os pedidos solicitados de recursos humanos médicos e não médicos e a preferência de que a dedicação ao neurodesenvolvimento fosse a tempo completo reflecte uma evolução positiva a curto prazo, caso estes recrutamentos se venham a concretizar.

Mutilação Genital Feminina: o que Sabem os Profissionais de Saúde?

Portugal is considered by the World Health Organization (WHO) a risk country for the practice of Female Genital Mutilation (FGM). Objectives: To evaluate the knowledge that health professionals from Maternity Dr. Alfredo da Costa (MAC) have regarding FGM. Population and Methods: Analysis of surveys delivered to health professionals from MAC (a hospital dedicated to reproductive health), between April and June 2008, addressing issues related to the knowledge about FGM. Results: Authors collected 112 valid surveys involving 38 doctors, 48 nurses and 26 medical auxiliaries/administrative personnel. From the respondents, 106 (95%) had heard about FMG practice before, the media being the most reported source of information; 59 (53%) replied they could be able to recognize FGM cases in their clinical practice; however, only 31 (28%) claimed to know the FGM type classiication and 32 (29%) admitted to be prepared to recognize and manage these situations in their own clinical practice; 9 had been consulted explicitly by a FGM practice complication and 1 doctor had admitted having been asked to perform/execute FGM; 13 (12%) recognized that the Portuguese legislation its this practice. Regarding the practice of FGM, 100 (89%) of respondentes stated that it should not be maintained and 97 (87%) stated that it should not be tolerated. However, 42 (38%) considered that if these practices were a reality, then they should be medical assisted. Discussion: Health professionals can play an important role in eliminating the practice of FGM, not only by the proper clinical management of this situation, but also by preventing those communities at risk to resort to FGM. Most health professionals are not prepared to deal with FGM in their clinical practice. It is important to promote a better knowledge on the subject and to create protocols for proper clinical management.

Estudo do Aborto Recorrente. Ainda há Lugar para a Histerossalpingografia?

Overview and Aims: The investigation of recurrent miscarriage includes the study of uterine morphology. 3D ultrasound allows the evaluation of the morphology (cavity and outer contour), reducing the need for invasive tests such as hystero - salpingography (HSG), hysteroscopy and laparoscopy. We evaluated the diagnostic agreement between HSG and 3D ultrasound in the study of the uterine cavity morphology. Study Design: Prospective study. Population: A total of 34 women referred to our institution with a history of recurrent miscarriage. Methods: To compare the results of 3D ultrasound and HSG, all women underwent both exams. 3D scans were performed by the same operator and HSG were evaluated by the same clinician. The concordance study was performed using the Kappa coefficient. Results: With 3D ultrasound and HSG, uterine anomalies were diagnosed in 52.9% (18/34) and 47% (16/34) of the cases and congenital malformations were the most frequent findings. The agreement between the two techniques was excellent(K = 0.825). The three cases of diagnostic disagreement were analyzed. Conclusion: A high level of diagnostic agreement was observed between HSG and 3D ultrasound. The 3D ultrasound, a low cost and well tolerated technique, when performed by an experienced operator, is the first line exam to study the uterine morphology in women with recurrent miscarriage.

Implante Contraceptivo Não Palpável - Estratégias para a sua Localização e Remoção

Overview and Aims: The contraceptive implant is frequently used to provide contraceptive protection over three years. The implant is inserted into the subcutaneous tissue of the upper arm, and should be palpable and easily removed. We evaluated the best imaging strategy for non-palpable implant (Implanon®) localization and removal. Study Design: Retrospective study. Population: A total of 11 women referred to a tertiary care hospital, between October 2009 and January 2012, for localization and removal of their non-palpable implants. Methods: Different localization methods (ultrasound and magnetic resonance imaging) were evaluated for non-palpable rod. Results: Seven of the nonpalpable implants were inserted in a health care center, three in a district hospital and one in a private clinic. In three women, the reasons for requesting removal were the end of the implant validity, two wanted to become pregnant, two had weight gain, one had weight loss, one referred irregular bleeding, one had two implants and one did a hysterectomy. In 81.8% (9) of the women, the implants were identified and localized by ultrasound, and successfully removed. In two patients the implant was not found and therefore not removed. Conclusions: In our study, high resolution ultrasound proved to be a sensitive method in implants localization, being the primary choice for determining the location of nonpalpable implants.

Saúde Sexual e Reprodutiva das Adolescentes - a Nossa Realidade

Overview and Aims: Several behavioral and biological factors can make adolescents particularly vulnerable to unwanted pregnancies and sexually transmitted diseases. The aim of this study was to evaluate sexual behavior and contraceptive use patterns of a population of adolescents. Study Design: Retrospective study. Population: 163 female adolescents attending an Adolescence Unit for the first time, during 2010. Methods: Analysis of clinical charts and assessment of demographic data, smoking and drinking habits, drug use, gynecologic and obstetric history, sexual behavior and contraceptive use. Results: The mean age was 16.04 years (±1.32). 71.7% were students (of these, 70% had failed one or more years and were behind in their studies), 2.5% were working and 23.9% were neither studying or working. 95.1% had already had sexual intercourse and the mean age of first coitus was 14.53 years (±1.24). There was a history of at least one previous pregnancy in 77.3% of the cases. Before the first appointment at the AU, the contraceptive methods used were: the pill (33.2%, but 41.3% of these reported inconsistent use), and the condom (23.9%, with inconsistent use in 28.3% of these cases). 19.6% did not use any contraceptive method.. After counseling at the AU, 54% of the teenagers chose the contraceptive implant and 35% preferred the pill. Adolescents who had already been pregnant preferred a long acting method (namely, the contraceptive implant)in 61.9% of cases; those who had never been pregnant decided to use an oral contraceptive in 67.6% of cases (p<0.001). Conclusions: After counseling the number of teenagers using contraception increased. In this population there were a high number of adolescents with a previous pregnancy. This factor seems to have influenced the choice of the contraceptive method, with most of these adolescents choosing a long-acting method.

Restrição do Crescimento Fetal - Casuística de 4 Anos

Overview and aims: Fetal growth restriction (FGR) affects 15% of pregnancies and is associated with both increased perinatal and neonatal morbidity and mortality and long-term effects in adult life. Our aim was to describe cases and outcomes of FGR from a tertiary perinatal care centre and identify the predictors of neonatal morbidity and mortality. Study design: retrospective cohort. Population: pregnancies with early or late FGR caused by placental factors followed from 2006 to 2009 in a tertiary perinatal care centre. Methods: we collected data from clinical records on demographics, clinical history and fetal ultrasound parameters. Perinatal and neonatal outcomes were stratiied according to gestational age (above or below 28 weeks) and we used bivariate analysis to identify any associations with clinical and imaging indings. Results: we included 246 pregnancies; hypertension was the most prevalent maternal risk factor (16%). There were 15 cases of early FGR, 11 of which had cesarean delivery due to deterioration of fetal Doppler parameters. Outcomes in this group included one fetal and three neonatal deaths. Of 231 cases of late FGR, 64% were delivered early given a non-reassuring fetal status i.e. due to changes in Doppler evaluation or altered Manning biophysical proile. There were four cases of perinatal death in this group, three of which delivered at 28 weeks. Neonatal morbidity was associated with lower gestational age, lower birthweight and progressive placental dysfunction (p<0.01). Conclusion: there was an association between neonatal morbidity and gestational age, birthweight and Doppler deterioration, particularly for deliveries below 28 weeks. The assessment of vascular changes through Doppler analysis allows anticipation of fetal deterioration and is a helpful tool in deciding the optimum timing of delivery.

Uma Complicação Grave da Embolização das Artérias Uterinas

Uterine artery embolisation has been used as a therapeutic alternative for symptomatic uterine myomas. It is considered a safe and effective procedure, with very few cases published involving complications. The authors present a case of a 35-year-old nulliparous woman with an intramural myoma with 161x143x85mm, submitted to an uterine artery embolisation complicated by uterine necrosis. A hysterectomy was performed. This casereport reinforces the idea that artery embolization is not a riskfree procedure and serious complications may occur. Therefore, patients should be carefully selected.

Insulino-Resistência e Aterosclerose

O tipo de vida nas sociedades ocidentais favorece, nos indivíduos geneticamente predispostos, o desenvolvimento do estado de insulino-resistência. Neste estado, são necessárias concentrações de insulina mais elevadas para que se obtenha uma normal resposta metabólica nos tecidos-alvo, ocasionando o desenvolvimento de hiperinsulinismo. Em consequência da multiplicidade de acções da insulina, a insulino-resistência está associada a disfunção de vários tecidos,orgãos e sistemas (Síndrome X), tendo por consequência, entre outras, um aumento do risco de patologia vascular aterosclerótica. Neste artigo, são revistas as alterações a nível do controlo da pressão arterial, endotélio vascular, metabolismo lipídico e sistema fibrinolítico, consequentes ao estado de insulino resistência e a forma como, junto com o hiperinsulinismo, aceleram o processo da aterogénese. São, igualmente, abordadas algumas das armas terapêuticas capazes de combater aquele estado e, assim, reduzir a morbilidade e mortalidade associadas à aterosclerose.

Levonorgestrel Intrauterine Device Effectiveness in Heavy Menstrual Bleeding Treatment in Obese Women

Objective:We aimed to identify if there was any difference in Levonorgestrel-releasing intrauterine system (LNG-IUS) efficacy or weight gain when used in heavy menstrual bleeding (HMB) treatment, between obese and non-obese women. Population and methods: This was a case-controlled retrospective study undertaken between 2002-2007. 194 women with HMB were treated with LNG-IUS and stratified into two groups accordingly with body mass index (BMI): Obese Group – BMI ≥ 30 (n=53) and Non-obese Group – BMI < 30 (n=141). Age, weight, days of spotting and days of menses were analyzed at 1, 3 and 6 months after insertion and then annually until 2 years. Analytic parameters of anemia (hemoglobin, serum ferritin, mean corpuscular volume) were reviewed at pre-insertion, at 6 months and then annually until 2 years. Results: During the 2-year follow-up there was a similar improvement in two groups regarding duration of menses, spotting and in analytic parameters of anemia. A statistically significant improvement was observed in obese group after 2 years of treatment regarding analytic parameters of anemia and menstrual characteristics, without weight gain. Conclusion: In obese women, the LNG-IUS is an effective treatment for heavy menstrual bleeding, without being associated to weight gain.

Torção Anexial

Adnexal torsion is a rare event whose diagnosis requires a high degree of suspicion since its presentation is clinical and laboratory nonspecific. Ultrasound constitute the first-line exam in the imaging evaluation and timely surgical treatment, with detorsion, is mandatory to allow the preservation of the structures involved. The effectiveness of preventive measures of recurrence is yet to be determined. In this paper, in addition to a literature review, the authors present a new imaging finding and propose a flowchart for therapeutic decision.

Sépsis Materna

Infections during pregnancy are prevalent. A small number of cases, however, may be life-threatening. Sepsis may be associated with multiple organ dysfunction and high mortality and it is one of the most common causes of direct maternal death often associated with the inability to recognize the severity of the illness. Long-term morbidity associated with maternal sepsis is significant and includes chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. The impact on neonatal mortality is also substantial, with over one million infection-related neonatal deaths eve - ry year. In the last few years, a vast number of clinical reviews of severe sepsis in pregnancy have been published, focusing on the characteristics of pregnant woman, the establishment of a specific treatment and the relevance of pregnancy surveillance by a multidisciplinary team. The treatment of sepsis is time-critical and requires early diagnosis, aggressive resuscitation, antibiotic administration and source control.

Rotura Uterina em Mulheres com Cesariana Anterior em Prova de Trabalho de Parto

Uterine rupture during a trial of labor after previous cesarean (TOLAC) delivery is a rare, but serious complication. Several factors can increase the risk of uterine rupture, so the assessment of individual risks with adequate counseling is ne - cessary. The initial signs and symptoms are usually nonspecific, hampering timely diagnosis and prompt delivery of the fetus, necessary for optimal outcome. The purpose of this document is to review the risks factors for uterine rupture during TOLAC, as well as the current clinical value of the classically described premonitory signs and symptoms.

Congenital Complete Atrioventricular Block. Case Report and Review of the Literature

Introduction: Congenital complete atrioventricular block (AVB) without cardiac malformation is a rare and potentially fatal condition. In most cases it is associated with maternal systemic lupus erythematosus through transplacental passage of antibodies anti-SSA/Ro and/or anti-SSB/La. Antenatal fluorinated-steroids have been successful in reversing first and second degree congenital AVB but inconsistent in third degree block. Case Report:The authors report a case of fetal bradycardia diagnosed at 24 weeks of gestation. The fetal echocardiogram revealed a second/third degree AVB without structural heart disease. Maternal anti-SSA/Ro antibodies were detected. There was no blockage improvement with maternal oral fluorinated-steroids. An elective cesarean section was performed at term with the delivery of a healthy girl that required an epicardical pacemaker on the 8th day of life. Conclusion: In this case, treatment with maternal fluorinated corticosteroids was not effective in preventing progression of the heart block.

Predição de Pré-Eclâmpsia no Primeiro Trimestre em Gravidezes de Baixo Risco: Determinação do Cut-Off numa Amostra da População Portuguesa

Objective:We aimed to identify the cut-off for risk of pre-eclampsia (PE) in Portuguese population by applying the first trimester prediction model from Fetal Medicine Foundation (FMF) in a prospective enrolled cohort of low risk pregnant women. Population and methods: A prospective cohort of low risk singleton pregnancies underwent routine first-trimester scree - ning from 2011 through 2013. Maternal characteristics, blood pressure, uterine artery Doppler, levels of pregnancy-associated plasma protein-A (PAPP-A) and free b-human chorionic gonadotropin were evaluated. The prediction of PE in first trimester was calculated through software Astraia, the outcome obtained from medical records and the cutoff value was subse quently calculated. Results:Of the 273 enrolled patients, 7 (2.6%) developed PE. In first trimester women who developed PE presented higher uterine arteries resistance, represented by higher values of lowest and mean uterine pulsatility index, p <0.005. There was no statistical significance among the remaining maternal characteristics, body mass index, blood pressure and PAPP-A. Using the FMF first trimester PE algorithm, an ideal cut-off of 0.045 (1/22) would correctly detect 71% women who developed PE for a 12% false positive rate and a likelihood ratio of 12.98 (area under the curve: 0.69; confidence interval 95%: 0.39-0.99). By applying the reported cutoff to our cohort, we would obtain 71.4% true positives, 88.3% true negatives, 11.4% false positives and 28.6% false negatives. Conclusion: By applying a first trimester PE prediction model to low risk pregnancies derived from a Portuguese population, a significant proportion of patients would have been predicted as high risk. New larger studies are required to confirm the present findings.