Abstract Overview and Aims: Sentinel lymph node (SLN) biopsy in endometrial cancer has emerged as an alternative to systematic lymphadenectomy, with cervical indocyanin green injection being the preferred method. Study Design, Population and Methods: A prospective cohort study to assess the feasibility of SLN mapping in EC using ICG and near-infrared (NIR) fluorescence is ongoing at the authors’ Gynaecological Oncology Unit, in a Portuguese level III care hospital. The authors conducted a descriptive analysis of the clinicopathologic characteristics and discuss the process of implementing a novel technique. Results: A minimum number of 20 patients with EC of all histologies and grades recruited until publication was established. Of all 20 patients, 12 (12/20; 60.0%) had a total laparoscopic hysterectomy plus bilateral salpingo-oophorectomy (TLH/BSO) and SLN biopsy alone, and the remaining 8 patients underwent full retroperitoneal staging (8/20; 40.0%). At least 1 SLN was detected in all patients (20/20; 100%), bilaterally in 14 (14/20; 70%) and unilaterally in 6 (6/20; 30%). In 1 case, a third SLN was identified amongst presacral nodes. No isolated para-aortic SLNs were detected. The median number of SLNs removed per patient was 2.3 (range 1-3). Out of the 20 patients, 2 (2/20; 10%) had lymph node metastases and in both cases bilateral detection of SLN did not occur. The median operative time was 240 minutes, with total SLN mapping time of approximately 40 minutes per side. Median operative time was lower among patients undergoing an SLN mapping only, compared with patients undergoing a full lymphadenectomy (219min vs 280min). No cases of ICG injection-related complications occurred. Ultrastaging of sentinel lymph nodes was performed in all cases. Conclusions: This is the first published series of laparoscopic sentinel lymph node biopsy using ICG and NIR fluorescence in endometrial cancer, conducted in a Portuguese hospital.

Resumo Introdução e Objetivos: A biópsia de gânglio sentinela (BGS) no carcinoma do endométrio surgiu como alternativa à linfadenectomia sistemática, privilegiando-se a injeção intracervical de verde de indocianina. Métodos: Foi realizado um estudo coorte prospetivo com o intuito de avaliar a reprodutibilidade da BGS com verde de indocianina no carcinoma do endométrio, num Hospital Português de nível III. Procedeu-se à análise descritiva das caraterísticas clinico-patológicas da população estudada e discussão do processo de implementação da nova técnica. Resultados: Estabeleceu-se um mínimo de 20 doentes com carcinoma do endométrio até publicação, incluindo todos os graus e tipos histológicos. Entre as 20 doentes recrutadas, 12 (12/20; 60%) foram submetidas a histerectomia total e anexectomia bilateral (HTL/AB) e BGS e as 8 restantes a estadiamento retroperitoneal completo (8/20; 40%). Foi detetado pelo menos 1 gânglio sentinela (GS) em todos os casos (20/20; 100%), bilateralmente em 14 (14/20; 70%) e unilateralmente em 6 (6/20; 30%). Um terceiro GS sagrado foi identificado num caso. Não se identificaram GS para-aórticos. O número médio de GS removidos em cada doente foi 2.3 (intervalo 1-3). Entre as 20 doentes, 2 (2/20; 10%) apresentaram metastização ganglionar e em ambos os casos não foi possível identificar bilateralmente o GS. O tempo operatório médio foi 240 minutos e o tempo dedicado ao mapeamento ganglionar 40 minutos, unilateralmente. O tempo operatório médio foi inferior nas doentes submetidas a BGS, comparativamente à linfadenectomia sistemática (219 minutos vs 280 minutos). Não houve complicações associadas à injeção do marcador. Foi realizado ultraestadiamento em todos os casos. Conclusões: A presente publicação é a primeira série de casos portuguesa reportada de biópsia de gânglio sentinela com verde de indocianina, por via laparoscópica no carcinoma do endométrio.

Abstract Overview and Aims: In early vulvar cancer, lymph node status is the most important prognostic factor. Sentinel lymph node biopsy (SLNB) is the minimally invasive procedure that leads to the most significant reduction in the classical high morbidity associated with the systematic inguinofemoral lymphadenectomy. Besides quality control, the aim of this study is to document and monitor the overall experience around SLNB at a referral Centre. Study design: Retrospective study. Population: All cases of vulvar carcinoma where SLNB was performed as part of the treatment for vulvar cancer at the authors’ Department, from January, 2016 to December, 2019 meeting the criteria: unifocal tumour confined to the vulva, tumour size < 4 cm, stromal invasion > 1 mm and no evidence of inguinal metastasis. Methods: Detailed description of the technique used in lymphoscintigraphy, SLNB, primary tumour treatment and histopathology with analysis of patient files collecting data of demographics, pathology, accuracy, surgery, perioperative results, feasibility and survival. Results: The average age was 68 years and Charlson score ≥ 5 was 55.6%. Primary site was labia majora in 44.4% and mid-line was affected in 27.8%. Mean tumour diameter was 20.2 mm. SLN detection rate was 100%, bilateral in 27.8%. 1 out of 38 nodes removed was positive and average number of nodes per patient was 2.1. There were no intraoperative complications. A single case of groin recurrence in 15 months mean follow-up time and 2 cases of non-related deaths occurred. 27.8% and 5.6% patients had short and long-term postoperative complications, respectively, mostly infectious. The average global survival/disease-free survival was 45.1/44.7 months. Conclusions: SLNB is a reliable and safe minimally invasive technique that should be performed by experienced gynaecological oncologists in well-equipped and multidisciplinary Centres. A rigorous preoperative planning combined with multidisciplinary surgical coordination are cornerstones for the success of this procedure applied to early-stage vulvar cancer.

Resumo Visão geral e objetivos: No cancro vulvar inicial, o estadiamento ganglionar é o fator prognóstico mais importante. A biópsia de gânglio sentinela (BGS) é o procedimento minimamente invasivo que ocasiona a redução mais significativa da elevada morbilidade associada à clássica linfadenectomia inguinofemoral sistemática. Além do controlo de qualidade, o objetivo deste estudo é documentar e monitorizar a experiência geral acerca da BGS num Centro de referência. Desenho do estudo: Estudo retrospetivo. População: Todos os casos de carcinoma vulvar em que a BGS foi realizada como parte integrante do tratamento para cancro vulvar no Departamento dos autores, de Janeiro de 2016 a Dezembro de 2019, cumprindo os seguintes critérios: tumor unifocal confinado à vulva, tamanho do tumor < 4 cm, invasão estromal > 1 mm e sem evidência de metástases inguinais. Métodos: Descrição detalhada da técnica utilizada na linfocintigrafia, BGS, tratamento do tumor primário e histopatologia com análise de processos clínicos dos pacientes, recolhendo dados demográficos, patológicos, de acurácia, acerca da cirurgia, resultados perioperatórios, de exequibilidade e de sobrevida. Resultados: A média de idades foi de 68 anos e o Índice de Charlson ≥ 5 foi de 55.6%. O local primário foi o grande lábio em 44.4% e a linha mediana foi afetada em 27.8%. O diâmetro médio do tumor foi de 20.2 mm. A taxa de deteção do GS foi de 100%, bilateral em 27.8%. 1 dos 38 gânglios linfáticos removidos foi positivo e o número médio de gânglios removidos por paciente foi de 2.1. Não se registaram complicações intraoperatórias. Um caso único de recorrência inguinal em 15 meses de tempo médio de seguimento e dois casos de óbitos não relacionados com a doença ocorreram. 27.8% e 5.6% dos pacientes tiveram complicações pós-operatórias de curto e longo prazo, respetivamente, principalmente de causa infeciosa. A média de sobrevida global/sobrevida livre de doença foi de 45.1/44.7 meses. Conclusões: A BGS é uma técnica minimamente invasiva confiável e segura que deve ser realizada por ginecologistas oncológicos experientes, em Centros multidisciplinares bem equipados. Um planeamento pré-operatório rigoroso aliado a uma coordenação cirúrgica multidisciplinar são os pilares para o sucesso deste procedimento aplicado ao cancro da vulva em estadio inicial.

Abstract Overview and Aims: The incidence of women in their antenatal and postpartum period who require hospitalization in the Intensive Care Unit (ICU), has been repeatedly used as a marker of quality for health services. In Portugal there are currently few studies that report on obstetric complications and the need for a more multidisciplinary approach after admission to an ICU. The main objective of this study is to determine the probability for intensive care admission need of this Centre’s obstetric population. The secondary objectives are to characterize the obstetric population, it’s risk factors and outcomes. Study design: Descriptive and retrospective study Population: All women hospitalized at an ICU in our Centre, during pregnancy or in the 42 days postpartum, in 2013 and 2020. Methods: We assessed the electronic and physical records of our eligible population and analyzed relevant variables such as maternal age, body mass index, gestational age at admission, and delivery route. Neonatal variables, such as weight at delivery, apgar scores and adverse neonatal outcomes were also evaluated. Results: During the study period, 41 women required hospitalization in ICU, out of a total of 14 688 births. The most frequent diagnosis at admission were hypertensive disorders and postpartum hemorrhage. Mean age was 30.4 years. Most admissions were in the postpartum period (97,6%). We observed two maternal deaths and one fetal death. Conclusions: The admission rate to the ICU was 2.8 per 1000 births. Most admissions occurred in the postpartum period (97.6%), with the most common reasons being hypertensive disorders (56.1%) and postpartum hemorrhage (31.7%). The maternal mortality rate was 0.14 per 1000 births. These results were similar to those found in other international and national studies.

Resumo Objetivo Comparar a abordagem laparoscópica com a laparotômica no estadiamento cirúrgico do carcinoma do endométrio. Métodos Avaliação retrospectiva de uma coorte de mulheres com diagnóstico préoperatório de cancro do endométrio submetida a estadiamento cirúrgico. As principais variáveis do estudo foram: morbilidade e mortalidade, tempo de internamento hospitalar, eventos adversos peri-operatórios e taxa de recorrência. A análise dos dados foi realizada com o programa SPSS v25 (IBM Corp, Armonk, NY, EUA), para as variáveis categóricas utilizou-se o teste do Qui-quadrado e o teste de Fisher, e para as variáveis contínuas o teste t de Student. Resultados A amostra foi constituída por 162 doentes. 138 pacientes preencheram os critérios de inclusão, 41 das quais foram submetidas a estadiamento por laparoscopia e 97 por laparotomia. As conversões de laparoscopia para laparotomia ocorreram em 2 doentes (4,9%) e foram secundárias a dificuldades técnicas e má exposição. A laparoscopia teve menos eventos adversos pós-operatórios quando comparada à laparotomia (7,3% versus 23,7%, respectivamente; p = 0,005), mas taxas semelhantes de complicações intraoperatórias, apesar do tempo operatório significativamente maior (mediana 175 a 130 minutos, respetivamente; p < 0,001). A permanência hospitalar foi significativamente menor na abordagem laparoscópica (mediana de 3 versus 7 dias, respectivamente; p < 0,001). Não houve diferenças nas taxas de recorrência ou mortalidade. Conclusão O estadiamento cirúrgico laparoscópico para carcinoma do endométrio é exequível e seguro. As doentes apresentam uma menor taxa de complicações pósoperatórias e tempo de internamento mais curto quando comparados aos da abordagem por laparotomia.

Abstract Objective To compare laparoscopy with laparotomy for surgical staging of endometrial cancer. Methods A cohort of women with preoperative diagnosis of endometrial cancer who underwent surgical staging was retrospectively evaluated. The main study end points were: morbidity and mortality, hospital length of stay, perioperative adverse events and recurrence rate. Data analysis was performed with the software SPSS v25 (IBM Corp., Armonk, NY, USA), categorical variables using a Chi-square and Fisher test, and continuous variables using the Student t-test. Results Atotal of 162 patientswere analyzed. 138 patientsmet the inclusion criteria, 41of whom underwent staging by laparoscopy and 97 by laparotomy. Conversions from laparoscopy to laparotomy happened in 2 patients (4.9%) and were secondary to technical difficulties and poor exposure. Laparoscopy had fewer postoperative adverse events when compared with laparotomy (7.3% vs 23.7%, respectively; p = 0.005), but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 175 vs 130 minutes, respectively; p < 0.001). Hospital stay was significantly lower in laparoscopy versus laparotomy patients (median, 3 vs 7 days, respectively; p < 0.001). No difference in recurrence or mortality rates were observed. Conclusion Laparoscopic surgical staging for endometrial cancer is feasible and safe. Patients have lower postoperative complication rates and shorter hospital stays when compared with the approach by laparotomy.

Overview and aims: This article addresses the diagnosis of anemia in the context of abnormal uterine bleeding and reviews the treatment options of iron deficiency anemia. This topic was worked out as a section of the Portuguese Consensus on Abnormal Uterine Bleeding, endorsed by the Portuguese Society of Gynaecology. The working group established recommendations that provide guidance to the medical society to better decision making concerning the treatment of iron deficiency anemia. We expose here evidence based guidelines consigning the diagnosis and management of this disease. Study design and Methods: A group of experts in the field performed a thorough systematic search of the publications on the treatment of iron deficiency anemia and a quality assessment of the included papers. On this basis a proposal was drawn up and later on was discussed and approved on consensus meeting with all members of the guidelines developing group reaching the final version of the recommendations. Conclusions: The present clinical practice guidelines on treatment of iron deficiency anemia may improve the diagnosis and management of this high prevalent disease.

Resumo Objetivo Avaliar se o pH da artéria umbilical (pHua) ≤7,00 e o déficit de bases da artéria umbilical (BDua) ≥12,00 mmol/L são preditores de desfechos neonatais adversos. Métodos Estudo observacional, longitudinal e retrospectivo, realizado no Serviço de Ginecolocgia e Obstetrícia do Centro Hospitalar Tondela Viseu durante o período de setembro de 2013 a setembro de 2015. Foi realizada a análise de toda a coorte e de dois subgrupos: grupo A-mulheres cuja gasometria do cordão umbilical (UCBGA, na sigla em inglês) foi realizada por traçado cardiotocográfico não tranquilizador, descolamento prematuro de placenta normalmente inserida, ou distócia de ombros; e grupo B -todas as outras. A análise estatística foi realizada com o programa SPSS for Windows, Versões 20.0 e 21.0 (IBM Corp., Armonk, NY, USA) Resultados Um total de 428 UCBGAs cumpriram os critérios de inclusão. A análise de grupo revelou uma associação entre o grupo A e pHua ≤7,00 (p = 0,002), e entre BDua ≥12,00 mmol/L e índice de Apgar ao 1o minuto ≤4 (p = 0,011). Após a aplicação dos modelos de regressão logística na análise da coorte total, pHua ≤7.00 teve impacto na ocorrência de hipóxia neonatal aguda (razão de probabilidade [RP]: 6,71; 95% índice de confiança [IC]: 1,21-37,06; p = 0,029); verificou-se maior risco de recém-nascido com índice de Apgar ao 1o minuto ≤4 e hipóxia neonatal aguda nas multíparas (RP: 5,38; 95% IC: 1,35-21,.43; p = 0,017; e RP: 2,66; 95% IC: 1,03-6,89; p = 0,043, respectivamente); e de recém-nascido com índice de Apgar ao quinto minuto ≤7 nas mulheres com problemas urológicos na gravidez (RP: 15,17; 95% IC: 1,29-177,99; p = 0,030); e a ocorrência de distócia de ombros aumentou 15 vezes o risco de hipóxia neonatal aguda (RP: 14,82; 95% IC: 2,20-99,60; p = 0,006). Conclusão OpHua e o BDua são preditores de desfecho neonatal adverso, e a UCBGA é uma ferramenta útil no rastreio dos recém-nascidos em risco. A realização universal de UCBGA deve ser considerada emtodos os partos, visto ser umteste de rastreio objetivo de hipóxia neonatal.

Abstract Objective To analyze if umbilical artery pH (pHua) ≤7.00 and umbilical artery blood deficit (BDua) ≥12.00 mmol/L are good predictors of adverse neonatal outcomes. Methods This was an observational, longitudinal and retrospective cohort study, conducted at the department of obstetrics and gynecology of Centro Hospitalar Tondela Viseu between September 2013 and September 2015. Total cohort and subgroup analysis were performed: group A-women with umbilical cord blood gas analysis (UCBGA) performed for non-reassuring fetal cardiotocographic patterns, placental abruption, or shoulder dystocia; and group B-all the others. Assays were made with the software SPSS for Windows, Versions 20.0 and 21.0 (IBM Corp., Armonk, NY, USA). Results A total of 428 UCBGAs met the inclusion criteria. The group analysis revealed an association between group A and pHua ≤7.00, as well as between BDua ≥12.00 mmol/L and 1st minute Apgar score ≤4 (p = 0.011). After the application of the logistic regression models in the total cohort analysis, pHua ≤7.00 had an impact in the occurrence of acute neonatal hypoxia (odds ratio [OR]: 6.71; 95% confidence interval [CI]: 1.21-37.06; p = 0.029); multiparous women had a higher risk of delivering a newborn with first minute Apgar score ≤4 and acute neonatal hypoxia (OR: 5.38; 95% CI: 1.35-21.43; p = 0.017; and OR: 2.66; 95% CI: 1.03-6.89, p = 0.043, respectively); women who had urologic problems during pregnancy had a higher risk of delivering a newborn with 5th minute Apgar score ≤7 (OR: 15.17; 95% CI: 1.29-177.99; p = 0.030); and shoulder dystocia represented a 15 times higher risk of acute neonatal hypoxia (OR: 14.82; 95% CI: 2.20-99.60; p = 0.006). Conclusion The pHua and the BDua are predictors of adverse neonatal outcome, and UCBGA is a useful tool for screening newborns at risk. Universal UCBGA should be considered for all deliveries, as it is an accurate screening test for neonatal hypoxia.

Resumo Objetivo O diagnóstico intraoperatório por congelação é umrecurso importante cujo uso empatologia ginecológica não tem sido suficientemente enfatizado. O objetivo do presente estudo foi avaliar as taxas de concordância entre o diagnóstico intraoperatório por congelação e o estudo anatomopatológico definitivo e determinar o quanto o diagnóstico intraoperatório por congelação é um método confiável. Métodos Um estudo retrospectivo de todos os diagnósticos intraoperatórios por congelação realizados em tumores uterinos e massas anexiais suspeitas entre janeiro e 2012 e dezembro de 2016 (excluindo metástases) no serviço de ginecologia e obstetrícia do Centro Hospitalar Tondela Viseu. Comparação do diagnóstico intraoperatório por congelação com o resultado do estudo definitivo em relação ao tipo histológico do tumor e profundidade de invasão miometrial. Resultados Um total de 286 casos foram elegíveis para o estudo, incluindo 102 (35.7%) tumores uterinos e 184 (64.3%) tumores ovarianos. A taxa global de casos deferidos foi de 5.2% (15/286). Entre os tumores uterinos, a acuidade de diagnóstico nos casos de carcinoma endometrial foi de 96.25% (77/80). Entre os tumores ovarianos, não se verificou concordância em 2 casos (1.1%), correspondendo a um tumor borderline do tipo seroso e a um adenocarcinoma de células claras intracístico. Conclusão O diagnóstico intraoperatório por congelação apresenta-se com um importante papel em situações selecionadas, sendo acompanhado de elevada taxa de sensibilidade e especificidade para tumores endometriais e ovarianos. A sua elevada acuidade diagnóstica encontra-se associada à possibilidade de obter um tratamento cirúrgico adequado na primeira abordagem cirúrgica

Abstract Objective Intraoperative frozen section (IFS) is a valuable resource, and its use in gynecological pathology has not been sufficiently emphasized. The main goal of the present study is to evaluate the reliability and agreement rates between IFS and the final paraffin section (PS) and determine how reliable IFS is. Methods A retrospective study of all IFSs performed on uterine tumors and suspicious adnexal masses between January 2012 and December 2016 (excluding metastases) at the department of obstetrics and gynecology of the Centro Hospitalar Tondela Viseu. Frozen versus permanent section diagnosis were compared regarding the histologic type of the tumor, and the depth of myometrial invasion. Results A total of 286 cases were eligible for the present study, including 102 (35.7%) IFSs of uterine tumors, and 184 (64.3%) IFSs of ovarian tumors. The overall rate of deferred cases was 5.2% (15/286). The accuracy of the diagnosis in cases of endometrial carcinoma was 96.25% (77/80). Among the ovarian tumors, misdiagnoses occurred in 2 cases (1.1%), corresponding to a borderline tumor (serous type) and a clear cell intracystic adenocarcinoma. Conclusion The IFS analysis plays an important role in selected situations and is associated to a high sensitivity and specificity in cases of ovarian and endometrial tumors. Its high accuracy is almost universally associated with the possibility of obtaining an optimal surgical treatment at the time of the first surgical approach.

Overview and aims: Standardization of screening tests lead to better care. The aim of this study was to describe and analyse screening practices during pregnancy among Portuguese Centres. Study Design and Methods: Written survey sent electronically to 41 public Portuguese Health Institutions which have an Obstetrics Department. Descriptive analysis of the collected data was performed. Results: Twenty-four surveys were obtained (58.5%). In most Centres combined aneuploidy screening is performed universally (79%). Preterm birth screening is performed through evaluation of cervical length at 20-22 weeks in most Centres (58%). A broad variety in performance was observed between Institutions regarding which infections were screened and their timing. Most institutions do perform preeclampsia screening (92%) and do not perform systematic evaluation of thyroid function in the absence of known pathology or signs/symptoms suggestive of thyroid disfunction. Conclusions: Although with some differences it was found that for preeclampsia, preterm birth and aneuploidy screening, the Centres have consistent practices