How Were Conflicts of Interest Handled?

Conflicts of interest were potentially great but they were minimized by the great conviction from both Doctors and Health Ministry that something had to be done to improve data on perinatal health. To decrease the number of hospitals where deliveries took place, to concentrate doctors, nurses and equipment, to define staff and to acquire equipment and to train nurses and paediatricians was the way. One the point of view of cost-effectiveness, centralization of expensive technologies, and development of expertise concentrating cases in a same centre - Surgery, VLBW, etc- and lowering mortality rates and get better outcomes were clear health gains. In 1989 after the political decision of closing small maternities the committee return to villages and cities to explain to political local power and people, the decision, which kind of care they will have in the future, why and expected gains. Level I hospitals and Health Centers stop to have deliveries; Health Centers were given a great responsibility: the follow up of the most part of the normal pregnancies by GP. There was no economic pressure because the National Health Service is free, there are no economic incentives for obstetrical or neonatal care, hospitals are financed through ICD, hospital level is defined according to both delivery and newborn care. In 1989 the rule was “No results can be obtained without the interested and responsible participation of all – institutions and people”. At that time the emphasis was on training. There are geographic influences on regionalization for example for islands and inner and far geographic areas. Also we would like to emphasize the influence of demographics on regionalization. As birth rate continues to decrease the hospitals left open 20 years ago with more than 1500 deliveries have to be closed now because the number of deliveries decreased. It was much more difficult and unacceptable to close some few maternities now than 20 years ago. All the difference was that at that time reasons were explained and now it was a Minister order. Other fearful events are the opening of private hospitals, the lowering gross national income, the economic difficulties and financial problems.

Perinatal Bacterial Infection: Screenning of Vertical Transmitted Infections

Perinatal bacterial infection may be caused by any microorganism colonizing the vaginal tract. Neonatologists and paediatricians are especially concerned about group B Stretpococcus (GBS). However, Enterobactereacea, mainly E.coli and Proteus, are also responsible for infection. GBS screening may be accomplished in over 90% of pregnant women. In our maternity in 2007-2008, 85% of the mothers had been screened. Screening and prophylaxis were responsible for a decreasing incidence of neonatal infection - from 0.6/1000 to 0.15/1000 live births in Portugal, from 2002 to 2007. However there are some difficulties related to screening. In the second Portuguese study 16/57 NB with early-onset infection (28%) were born to “negative” mothers. Several factors illustrate how difficult is to draw national screening policies: a wide range of carrier’s state rate throughout a country - in Portugal from 12% to 30%. The success of any screening policy may also be affected by additional technical and organizational problems. In countries where home delivery is a tradition or a trend intrapartum GBS prophylaxis requires a very well organized assistance.. Moreover factors usually accepted as protective are not so effective. In the Portuguese study 24/57 infected newborns (42%) were delivery by caesarean section. Another subject deals with the workload in the postnatal ward generated by deficient compliance to the guidelines a problem not confirm by a study of our group. Decreasing the importance of GBS, highlight the importance of E. coli in perinatal infection. From the 16 340 registrations of the National Registry 1676 were newborns with mother-related infection. Applying the same reasoning to E.coli as to GBS and Listeria monocytogenes – that is considering all of them are of maternal origin - 6.7% of these infections were due to E. coli, 4.6% to SGB and 0.5% to Listeria monocytogenes. In conclusion screening and prophylaxis may be not the best way to prevent all GBS neonatal infections but by now it is the only available procedure. The other bacteria continue to demand a high suspicion level and immediate intervention.

Induced Labor– Is There an Increased Risk of Perinatal Infection?

Objectives: To assess induced labor-associated perinatal infection risk at Hospital D.Estefânia from January to June of 2010 at Hospital de D. Estefânia’s delivery rooms, reviewing the indications for inducing labor as well as the techniques used. Material and Methods: Performing an historical prospective study searching the clinical processes as well as the mother and newborn’s computer database from January to June of 2010. An exposed and an unexposed group were created; the first group comprises pregnant women and their newborns whose labor was induced. The unexposed group is constituted by newborns and pregnant women whose labor was spontaneous. Labor induction was performed using intra-vaginal prostaglandins in women who didn’t start it spontaneously; perinatal infection was defined either clinically or using blood tests. The gestational age was ≥ 37 weeks for both groups. 19 variables were studied for both groups. Results: A total of 190 mother-newborn pairs were included: 55 in the exposed group and 135 in the unexposed group. 3 cases of perinatal infection were reported, two in the exposed group and one in the unexposed group. Preliminary data resulted in a perinatal infection rate of 3.6% in the exposed group and 0.7% in the unexposed group; preliminary data suggest that the risk of perinatal infection may be increased in up to 5-fold when labor is inducted. Conclusions: A larger series of patients and a multivariable analysis using logistic regression are both necessary in order to perform a more thorough assessment of labor induction’s role in perinatal infection risk. One must also try to distinguish labor inducing- and clinical practicesrelated factors.

Why and How Was Regionalization of Perinatal Care Accomplished in Portugal?

Portuguese health care system was created in 1979. It is universal and for free. Expenses are supported by the State through taxes. The modern perinatal care system started by the end of 1970. The first neonatal intensive care units were created in 1980, the Portuguese Neonatal Society in 1985 and the National Neonatal Transport System in 1987. Until the seventies of twentieth century and even during eighties there were more than 200 hospitals with deliveries, a great part without obstetrician or paediatrician, a great percentage of pregnancies had no prenatal care, there were few neonatal intensive care units and perinatal mortality rate was one of the highest in the European countries. In 1987 an Experts Committee was nominated by the Health Ministry aiming to collect and analyse data on perinatal care and to suggest improvements. The Report resulting from this work is the main document on which is based the reform. The reform was a 9 years program in 3 years stages aiming to close hospitals with less than 1500 deliveries/year, to reclassify hospitals, to create Coordinating Units between health centres and hospitals, to equip neonatal intensive and intermediate care units, to define needs of obstetricians, paediatricians and nurses for each centre and to promote specialised training in neonatology for paediatricians and nurses. Levels of perinatal care were defined as well as localization of each level of hospital according to the number of deliveries in one geographic area, geographic difficulties and existing routes and connections. Steps for opening and closure of different levels of hospitals were very well programmed. The organization, capacities, number of obstetricians, neonatologists and nurses as well as equipment for each level of care was defined. Rules for pregnant women and newborns transfer from level II to level III hospitals were also well described. A specific training is neonatology was created starting in 1990. This organization resulted in an impressive decrease in mortality rates at all levels and still it is the policy we have today.

Historical Roots of Histrionic Personality Disorder

Histrionic Personality Disorder is one of the most ambiguous diagnostic categories in psychiatry. Hysteria is a classical term that includes a wide variety of psychopathological states. Ancient Egyptians and Greeks blamed a displaced womb, for many women's afflictions. Several researchers from the 18th and 19th centuries studied this theme, namely, Charcot who defined hysteria as a "neurosis" with an organic basis and Sigmund Freud who redefined "neurosis" as a re-experience of past psychological trauma. Histrionic personality disorder (HPD) made its first official appearance in the Diagnostic and Statistical Manual of Mental Disorders II (DSM-II) and since the DSM-III, HPD is the only disorder that kept the term derived from the old concept of hysteria. The subject of hysteria has reflected positions about health, religion and relationships between the sexes in the last 4000 years, and the discussion is likely to continue.

A Case of Late-Diagnosed Ovotesticular Disorder of Sex Development

We report acase of!ovotesticular disorder of sex development!(DSD) with ambiguous genitalia, 46XX presenting the clinical, laboratory, imaging and operative findings and highlighting the pertinent features of this case. Results of hormonal, genetic testing and histopathology findings are reviewed. Diagnosis of true hermaphroditism is well defined and the condition can be recognized even prenatally. Conservative gonadal surgery is the procedure of choice after the diagnosis of true hermaphroditism, if the risk of a gonadal malignancy is low. Continued follow-up is necessary because of the multiple psychological, gynecological and urological problems encountered postpubertally by these patients.