Abstract Introduction: Mode of delivery is known to have a major impact on the health of women and neonates and should therefore be carefully considered. Moreover, expectations built during pregnancy influence the way pregnant women experience labor and delivery. Materials and Methods: Cross-sectional descriptive study conducted between February and August 2021 in a tertiary hospital in Portugal. Pregnant women from the the 30th week of gestation, with no contra-indication for vaginal delivery were included. A two-page multi-choice and short-answer questionnaire was handled, which included questions on sociodemographic characteristics, on delivery preferences and on reasons for those preferences. Results: 303 of the 344 (88,1%) women included wished for a vaginal delivery. The main reason for preferring a vaginal delivery was “it is more natural” (80.2%), followed by “post-partum is easier and recovery is faster”. Regarding women with a preference for cesarean section, most of them believe that it is safer for the baby. The majority (66,7%) of women with a cesarean in the past would prefer a vaginal delivery in the current pregnancy. Discussion: Although safe, a cesarean comprises higher risks for maternal and neonatal health when compared to a vaginal delivery. Globally, most women prefer a vaginal delivery. The way women experience previous labors seems to influence the subsequent pregnancies. Conclusion: Most of the women in our sample preferred a vaginal delivery. However, 11,9% of pregnant women with no indication for a surgery would choose a cesarian section. The fact that many women consider that for the baby the cesarian is the safest mode of delivery should lead the clinicians to reflect and invest in transmitting precise information.

Resumo Introdução: A via de parto tem um impacto importante na saúde materna e neonatal e, por este motivo, deve ser cuidadosamente ponderada. Por outro lado, as expetativas que as mulheres constroem durante a gravidez influenciam a forma como experienciam o parto. Materiais e Métodos: Estudo transversal descritivo conduzido entre fevereiro e agosto de 2021 num hospital terciário em Portugal. Foram incluídas mulheres com 30 ou mais semanas de gestação sem contraindicação para parto vaginal. Foi entregue um questionário de duas páginas incluindo questões sociodemográficas, questões sobre a preferência relativamente à via de parto e sobre as motivações para essa preferência. Resultados: 303 das 344 (88,1%) mulheres incluídas no estudo referiram preferir um parto por via vaginal. A principal razão para esta escolha foi “é mais natural” (80,2%), seguido de “o pós-parto é mais fácil e com recuperação mais rápida”. Relativamente às mulheres que mencionaram preferir uma cesariana, a maioria acredita que esta via de parto “é o mais seguro para o bebé”. A maioria (66,7%) das mulheres com uma cesariana no passado desejaria um parto por via vaginal na gravidez atual. Não encontrámos relação entre os fatores sociodemográficos e a preferência relativamente à via de parto. Discussão: Apesar de seguro, um parto por cesariana tem maior impacto negativo na saúde materna e neonatal quando comparado com um parto vaginal. Globalmente, a maioria das mulheres prefere um parto por via vaginal. A vivência em partos anteriores parece ter uma influência importante na forma como as mulheres experienciam as gestações subsequentes. Conclusão: A maioria das mulheres da nossa amostra referiu preferir um parto vaginal. No entanto, 11,9% das mulheres sem indicação para cirurgia mencionaram preferir uma cesariana. O facto de que muitas mulheres percecionam a cesariana como o mais seguro para o bebé deve levar os clínicos a refletir e a investir na transmissão de informação correta.

Abstract Introduction: External cephalic version (ECV) is a procedure to change the presentation of the fetus from breech, transverse, or oblique to vertex by applying pressure externally to the fetus through the gravid abdomen. Aim: To evaluate the use of external cephalic version (ECV) among the portuguese obstetric community and the reasons for not performing this procedure. Study design: Cross-sectional study. Population: Doctors attending the 5th national Congress of Obstetrics and Maternal-Fetal Medicine in 2019. Methods: A cross-sectional survey using self-administered questionnaires was conducted among doctors attending the national obstetrics congress in 2019. The survey evaluated the local of work, the level of experience, motivation, and capability of performing an ECV by the participants as well as the reasons for not suggesting or performing an ECV. The statistical analysis included descriptive and comparative analysis. The chi-square test was used with a significance level < 0,05. Results: Ninety-nine clinicians answered the questionnaire; fifty-two worked in a differentiated perinatal hospital. ECV was mainly recommended by doctors from differentiated perinatal hospital (n=29) when compared to doctors from private hospitals (n=2) and perinatal hospitals (n=10) (p =0,010). Most clinicians (n=58) would not recommend this procedure to pregnant women. The main reasons for this were the lack of clinical experience (n=39) and the fact that participants believed that cesarean was a more adequate procedure (n=15). Eighty-one participants were interested in attending training sessions to learn how to perform an EVC in safe conditions. Conclusion: Overall, ECV is not widely practiced in Portugal despite being a safe procedure recommended by the Portuguese Society of Obstetrics and Maternal-Fetal Medicine. Efforts should be done to implement this safe technique among clinicians through training sessions or to enhance referral of these patients to institutions where ECV is performed.

Resumo Introdução: A versão cefálica externa (VCE) permite, utilizando manobras externas sobre o abdómen materno, converter um feto em apresentação não cefálica num feto em apresentação cefálica. Objetivo: Avaliar a opinião da comunidade obstétrica nacional sobre a VCE e quais os condicionantes para a sua não realização. Desenho do estudo: Estudo transversal. População: Médicos que participaram no V Congresso Nacional de Obstetrícia e Medicina Materno-Fetal em 2019. Métodos: Distribuição de questionários anónimos aos participantes do congresso. O questionário avaliou o local de trabalho habitual, o nível de experiência clínica do inquirido, a experiência, motivação, e capacidade de realização da VCE e as razões apresentadas pelos clínicos para não proporem/realizarem a manobra. A análise estatística incluiu a analise descritiva e comparativa. Foi utilizado o teste qui-quadrado e considerou-se um nível de significância de p<0,05. Resultados: Noventa e nove médicos responderam ao questionário. A maioria dos participantes (n=58) não proporia a VCE às grávidas. As principais razões apontadas foram a falta de experiência na realização da manobra (n=39) e o facto de os participantes considerarem a cesariana um procedimento mais adequado (n=15). Cinquenta e dois pertenciam a um hospital de apoio perinatal diferenciado. A VCE foi proposta com maior frequência nos hospitais de apoio perinatal diferenciado (n=29) face aos hospitais de apoio perinatal (n=10) e hospitais privados (n=2), (p=0,010). A maioria dos participantes (n=81) estaria interessado em participar em sessões de treino sobre a execução da manobra. Conclusão: A VCE não parece ser amplamente realizada nos hospitais portugueses, apesar de ser uma manobra segura e recomendada pela Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal. É fundamental difundir a VCE na comunidade obstétrica nacional, investir em sessões de formação para que os clínicos adquiram competências na sua execução e fomentar a referenciação destas doentes para centros onde a VCE seja realizada.

Abstract Objective To assess obstetric/puerperal/neonatal outcomes in an inflammatory bowel disease (IBD) population and to analyze disease characteristics that may be associated to adverse outcomes. Methods Retrospective descriptive analysis including 47 pregnant women with IBD (28 with Crohn's disease – CD and 19 with ulcerative colitis – UC) who delivered between March 2012 and July 2018 in a tertiary hospital. We reviewed clinical records to extract demographic information, previous medical history, disease subtype, activity, severity, treatment, and obstetric, puerperal, and neonatal outcome measures. Results Obstetric and neonatal complications (composite outcomes) occurred in 55.3% and 14.6% of the IBD population, respectively, and were more frequent in UC patients. Preterm birth (PTB), preeclampsia, anemia, low birth weight (LBW), and neonatal death were also more frequent in UC patients. The rate of postpartum hemorrhage (PPH) was 14.9%, and it was higher in CD patients. Women with active IBD had more obstetric/neonatal adverse outcomes (fetal growth restriction and LBW in particular) and cesarean sections. Patients with medicated IBD had less obstetric/neonatal complications (PTB and LBW in specific) and cesarean sections but more PPH. Conclusion Women with IBD may have an increased risk of obstetric/puerperal/neonatal adverse outcomes. Ulcerative colitis patients had more obstetric and neonatal complications, whereas PPH was more frequent if CD patients. Other disease characteristics were considered, which allowed a better understanding of their possible influence. Although more research is needed, this work reinforces the importance of adequate surveillance to allow prompt recognition and treatment of complications.

Resumo Objetivo Avaliar os desfechos obstétricos/puerperais/neonatais em uma população com doença inflamatória intestinal (DII) e analisar as características da doença, que podem estar associadas a desfechos adversos. Métodos Análise descritiva retrospectiva incluindo 47 gestantes com DII (28 com doença de Crohn – DC e 19 com retocolite ulcerativa – RCU) que deram à luz entre março de 2012 e julho de 2018 em um hospital terciário. Revisamos os registros clínicos para extrair informações demográficas, histórico médico prévio, subtipo da doença, atividade, gravidade, tratamento e medidas de resultados obstétricos, puerperais e neonatais. Resultados As complicações obstétricas e neonatais (desfechos compostos) ocorreram em 55,3% e 14,6% da população com DII, respectivamente; e foram mais frequentes em pacientes com RCU. Nascimento prematuro (PTB), pré-eclâmpsia, anemia, baixo peso ao nascer (BPN) e óbito neonatal também foram mais frequentes em pacientes com RCU. A taxa de hemorragia pós-parto (HPP) foi de 14,9% e foi maior em pacientes com DC. Mulheres com DII ativa tiveram mais desfechos obstétricos/neonatais adversos (restrição de crescimento fetal e BPN em particular) e cesarianas. Pacientes com DII medicada tiveram menos complicações obstétricas/neonatais (PTB e BPN em específico) e cesarianas, mas mais HPP. Conclusão Mulheres com DII podem ter um risco aumentado de desfechos adversos obstétricos/puerperais/neonatais. As pacientes com RCU apresentaram mais complicações obstétricas e neonatais, enquanto a HPP foi mais frequente em pacientes com DC. Outras características da doença foram consideradas, o que permitiu uma melhor compreensão de sua possível influência. Embora mais pesquisas sejam necessárias, este trabalho reforça a importância de uma vigilância adequada para permitir o reconhecimento e o tratamento imediatos das complicações.

Abstract Objective: To assess the coverage rates of Influenza vaccination in pregnant women, to identify the reasons for non-immunization and to compare with the Bordetella pertussis vaccination rate in pregnancy. Methods: Observational prospective study performed between January and February of 2020. In the postnatal ward, a self-administered questionnaire about flu vaccination and the reasons for non-vaccination was delivered. Chi squared and Fisher’s exact tests were performed. Results: In the postnatal ward 117 women answered the questionnaires - 49% were vaccinated against influenza. The main cause for the non-vaccination was the lack of recommendation (61%), followed by the fear of adverse effects (20%). Vaccination during pregnancy was more frequent when the antenatal care was provided at public hospital versus primary care or private care (respectively 68%, 31% e 47%, p=0.023), when the pertussis vaccine was performed (96% vs 79%, p=0.005) and when women had adequate information on flu severity in pregnancy and to the neonate (65% vs 41%, p=0.013) and knew the potential benefits of influenza vaccination during pregnancy in preventing flu in the first months of life of the neonate (76% vs 29%, p<0.001). Conclusion: In our population, the reduced vaccination coverage (49%) was essentially linked to lack of recommendation about influenza vaccination during pregnancy by healthcare providers.

Resumo Objetivo: Avaliar a taxa de cobertura vacinal da gripe na gravidez, as razões para a não vacinação e comparar com a taxa de vacinação contra a Bordetella pertussis nas grávidas. Métodos: Estudo observacional prospetivo que decorreu entre janeiro e fevereiro de 2020. No internamento de puerpério, foi aplicado um inquérito de autopreenchimento sobre a vacinação contra a gripe, incluindo os motivos da não vacinação. Aplicaram-se os testes Qui-quadrado ou o teste exato de Fisher. Resultados: No internamento de puerpério obtivemos 117 respostas aos inquéritos - 49% referiram estar vacinadas contra a gripe. O principal motivo para a não vacinação foi a ausência de recomendação (61%), seguido do receio de efeitos adversos (20%). A vacinação foi mais frequente em grávidas vigiadas em consulta hospitalar do SNS comparativamente com as grávidas vigiadas nos cuidados primários e no setor privado (respetivamente 68%, 31% e 47%, p=0,023), em mulheres vacinadas contra a tosse convulsa (96% vs 79%, p=0,005) e em grávidas informadas sobre a gravidade da gripe (na grávida e no recém-nascido) (65% vs 41%, p=0,013) e sobre a possibilidade da vacina prevenir a doença nos primeiros meses de vida do filho (76% vs 29%, p<0,001). Conclusão: Na nossa amostra, a baixa cobertura vacinal (49%) associou-se essencialmente à falta de recomendação da vacinação contra a gripe por parte dos profissionais de saúde que acompanham a gravidez.

Resumo Introdução: A doença de Behçet (DB) é uma vasculite sistémica de causa indeterminada. Várias citocinas, como o TNF-α, parecem desempenhar um papel na patogénese. Desde modo, o uso de biológicos como fármacos anti-TNF-α têm aumentado, no controle das manifestações graves ou refratárias da DB. Este estudo teve como objetivo a descrição dos resultados obtidos com biológicos na DB. Material e Métodos: Estudo longitudinal, prospectivo, uni-cêntrico de doentes seguidos em consulta especializada. Recolhemos dados relativamente às manifestações, tratamentos e resultados obtidos durante o seguimento. Resultados: A coorte inclui 243 doentes, 31% homens. Vinte doentes (8%) realizaram biológicos. Os doentes que foram submetidos a biológicos são mais novos (p = 0,030), têm menos aftose genital (p = 0,009), e mais frequentemente eritema nodoso (p = 0,009), poliartrite (p = 0,002), espondiloartrite (p = 0,024), vasculite retiniana (p = 0,011) e manifestações gastrointestinais (p = 0,024), nomeadamente úlcera gastroduodenal (p = 0,035), hemorragia digestiva (p = 0,002), e perfuração intestinal (p = 0,004). Foram usados fármacos anti-TNF-α em todos os doentes, mais frequentemente infliximab. Os biológicos foram iniciados após falência de resposta aos imunossupressores clássicos, e a maioria dos doentes entrou em remissão da doença após (93%). Três doentes desenvolveram tuberculose durante o tratamento, apesar de efetuarem testes de rastreio regulares. Foi possível parar o biológico em cinco doentes até então, sem recorrência, com um período médio de seguimento de 33 meses desde a suspensão. Discussão: Os biológicos anti-TNF-α são altamente eficazes nas manifestações da DB refratária, embora não sejam inócuos. Pouco se sabe relativamente à duração ótima destas terapêuticas, quando e como parar. Isto é importante não só para evitar recidivas, mas também para reduzir os efeitos secundários.

Abstract Introduction: Behçet´s disease (BD) is a systemic vasculitis of unknown cause. Several cytokines, such as tumor necrosis factor-alpha (TNF-α), appear to play a substantial role. Therefore, biologics such as anti-TNF-α agents are rising to control severe or refractory BD´s manifestations. We aimed to describe the biological therapy´s outcomes in BD patients. Methods: A longitudinal, prospective, unicentric cohort study with patients followed in a specialized outpatient clinic. We collected data regarding BD´s manifestations, treatments, and outcomes during follow-up. Results: Our cohort includes 243 patients, of whom 31% were male. During follow-up, 20 patients (8%) were treated with biological drugs. Patients who received biological therapies were younger (p = 0.030), had less frequently genital aphthosis (p = 0.009), and more frequently erythema nodosum (p = 0.009), polyarthritis (p = 0.002), spondyloarthritis (p = 0.024), retinal vasculitis (p = 0.011) and gastrointestinal manifestations (p = 0.024), namely gastroduodenal ulcer (p = 0.035), digestive bleeding from ulcers (p = 0.002), and bowel perforation (p = 0.004). Anti-TNF-α agents were used in all of these patients, most frequently infliximab. Patients started biologicals after classical immunosuppressors failure, and most went into remission (93%). Three patients developed tuberculosis during treatment, regardless of regular screening tests. It was possible to stop biological therapy in five patients, so far, without recurrence, with 33 months of mean follow-up time after suspension. Discussion: Anti-TNF-α agents are highly effective for re-fractory BD´s manifestations, although they are not innocuous. Little is known about the optimal duration of these therapies, regarding when and how to stop these drugs. This issue is essential not only to avoid relapses but also to reduce therapy side-effects.

Abstract Acute Kidney Injury (AKI) caused by bilateral compression of the ureters by the gravid uterus is a rare complication of pregnancy. We describe the case of a pregnant woman who presented with obstructive AKI, developing severe complications (severe renal hypofunction, fetal growth restriction and urinary tract infections) and requiring invasive treatment. After exclusion of other causes, the diagnosis of AKI caused by bilateral compression of the ureters by the gravid uterus was established and double-J catheters were placed bilaterally with progressive resolution of the condition.

Abstract Loeys-Dietz syndrome is a rare autosomal dominant connective tissue disorder characterized by vascular, skeletal, craniofacial and cutaneous abnormalities. During pregnancy, women with this syndrome have an increased risk of aortic aneurysm and dissection, preterm birth, uterine rupture and postpartum hemorrhage. Appropriate preconceptional, pregnancy and postpartum evaluation, counseling and surveillance by a specialized and multidisciplinary team might improve maternal and pregnancy outcomes. We present two cases of pregnant women with this syndrome surveilled at a tertiary high-risk obstetrics center. Both delivered at term without major complications.

Abstract Overview and aims: Obstetric care during delivery is guaranteed for 24 hours a day in the national health system. The aim of this work is to assess the differences in the clinical activity of a labour ward between day and night periods. Study design: Descriptive retrospective study. Population: Pregnant women whose deliveries occurred at a tertiary Portuguese hospital between 1 st January 2018 and 29 th February 2020. Methods: We included all the deliveries of a tertiary Portuguese hospital, divided in two periods - day (9am-9pm) and night (9pm-9am). Results: A total of 5306 births have occurred during this period. Of these, 43.1 % (2286) occurred during the night. The distribution of deliveries was balanced between the two periods considered in this study. Urgent or emergent caesareans took place mainly between 23pm and 1am. There were no differences regarding adverse maternal or perinatal outcomes, except for a higher rate of admissions into the neonatal intensive care unit during the day (p=0.01). Conclusions: There were no differences in the number of deliveries or complications between the day and the night periods. This reinforces the need to guarantee an adequate number of members composing the emergency teams, both doctors and nurses, 24 hours a day. It is also of paramount importance to guarantee the support of both Neonatologists and Anaesthesiologists.

Smoking is the leading avoidable cause of adverse outcomes in pregnancy. Smoking cessation has been clearly associated with health benefits to both mother and foetus. However, only a minority of smokers will cease. Healthcare professionals’ guided interventions could be a critical step in prenatal smoking cessation, requiring knowledge in the management of non-pharmacological and pharmacological techniques. The data from available trials has not yet succeeded to assess the safety and effectiveness of pharmacological methods in pregnancy and breastfeeding. Thus, the recommendations support preferably the use of non-pharmacological strategies.

In the past, accidental detection of an adnexal tumor in pregnancy was a rarity, occurring most often during a caesarean section. This diagnosis has become more common due to the widespread use of ultrasound in early pregnancy. Most of these tumors are benign and spontaneously resolve, but if they persist there is a risk of torsion, rupture, or obstruction of labor. The possibility of dealing with cancer should also be considered. The clinical management can be challenging, so it's essential to establish the diagnostic criteria and to define the expectant or surgical approach to adopt