Publications by authors named "Paulo Moura"

31 Publications

Physician awareness regarding contraceptive counselling in women with chronic disease.

Eur J Contracept Reprod Health Care 2021 Mar 15:1-7. Epub 2021 Mar 15.

Department of Obstetrics-A, Coimbra Hospital and University Centre, Coimbra, Portugal.

Introduction: Contraceptive counselling is essential in women with chronic disease, though it is frequently overlooked. We aimed to assess practices and awareness in contraceptive counselling in hospital physicians caring for reproductive age women with chronic disease.

Methods: A questionnaire was distributed in April 2017 to physicians from 16 medical specialties in a tertiary care hospital in Portugal. Statistical analysis performed using Microsoft Office Excel and IBM SPSS-Statistics.

Results: Two-hundred physicians participated in the survey: 59.5% were female, 55% under 35 years-old and 48.5% were residents. Only 26.5% practiced in surgical specialties. Two-thirds consistently inquired about the use of contraception. Most referred patients to Family Planning services or performed contraceptive counselling when pregnancy posed significant health risks (89.0%), when prescribing teratogenic medication (79.5%) or drugs with potential interaction with contraceptives (75.0%). Lack of training in contraception was the main reason for not referring patients to Family Planning services. While 83% considered counselling very important, only 5% had recently undergone training and 12.5% felt knowledgeable enough to perform it. Only 12.5% were aware of the institution's Family Planning resources. Female gender, non-surgical specialty, age over 35 years-old and over 10 years since specialisation were positively associated with awareness.

Conclusion: Most physicians addressed contraceptive management in women with comorbidities, but adequate training is lacking. Our results highlight the importance of communication between health care providers to achieve an adequate and multidisciplinary approach to reproductive and general health goals.
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http://dx.doi.org/10.1080/13625187.2021.1891409DOI Listing
March 2021

[Pregnancy and Hemodialysis: About a Successful Twin Pregnancy].

Acta Med Port 2021 Jan 4;34(1):56-58. Epub 2021 Jan 4.

Departamento de Obstetrícia A. Maternidade Doutor Daniel de Matos. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal.

Pregnancy is a rare condition in women with chronic kidney disease on hemodialysis, but its incidence has increased in recent years. Despite being a high-risk condition for both mother and fetus, there has been an improvement in care due to the increased number of cases described and the experience gained in dialysis therapy. We report the case of a multiparous 32-years-old women with chronic hypertension and chronic kidney disease with 10 years of evolution and difficult control, with a diagnosis of dichorionic/diamniotic twin pregnancy, 4 months after beginning hemodialysis. Pregnancy was managed by a multidisciplinary team, hemodialysis sessions were clinically and hemodynamically well tolerated, with good blood pressure and analytical control, as well as adequate development of both fetuses. She went into labor at 34 weeks and 6 days, so a caesarean section was performed, with 2 boys born with adequate weight for gestational age.
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http://dx.doi.org/10.20344/amp.11377DOI Listing
January 2021

Menstrual pattern and contraceptive choices of Portuguese athletes.

Eur J Contracept Reprod Health Care 2021 Feb 22:1-10. Epub 2021 Feb 22.

Obstetrics Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Objectives: Menstrual symptoms are commonly cited barriers to physical activity in women. Delay or avoidance of menstruation through hormonal contraceptives may mitigate those barriers. Our purpose is to identify the uterine bleeding patterns of Portuguese athletes, their contraceptive choices and the impact of contraceptive methods in sports performance. We aim also to compare the outcomes between users and non-users of contraception.

Methods: Observational, descriptive and comparative study based on a customised self-assessment online survey aimed at Portuguese athletes. Athletes had to be at least 16 years old and competing at a national, international or professional level.

Results: A total of 256 athletes from 18 modalities were eligible. The mean age was 29 years and the mean age of menarche was 12.8 years. Monthly bleeding pattern was prevailing and 50% presented dysmenorrhoea. More than 85% experience fluctuations in sports performance throughout the month. The majority (71.5%) used contraceptive methods. Only 16% believed that contraception decreased sports performance. Contraceptive users exhibit a lower mean body mass index, blood loss and percentage of dysmenorrhoea than the non-users.

Conclusion: Most athletes had the perception that performance varies throughout the month. The majority of participants do not report amenorrhoea and have monthly menses. The use of contraceptive methods is reportedly high, benefit cycle control and apparently without any physical inconvenience.
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http://dx.doi.org/10.1080/13625187.2021.1879780DOI Listing
February 2021

Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: A case report.

Case Rep Womens Health 2019 Oct 10;24:e00144. Epub 2019 Oct 10.

Obstetrics and Gynecology Department, Centro Hospitalar e Universitário de Coimbra, Maternidade Doutor Daniel de Matos, R. Miguel Torga, 3030-165, Coimbra, Portugal.

Spontaneous heterotopic pregnancies occur in about 1/30000 pregnancies, with the ovarian subtype comprising 2.3% of the total. We report the case of a healthy 32-year-old woman, gravida 4, para 3, who presented to the emergency room with severe abdominal pain. Two weeks earlier, pelvic ultrasound had revealed a 6-week intrauterine pregnancy. She was hemodynamically stable, but had rebound tenderness on the right iliac fossa. Transvaginal ultrasound revealed an evolutive intrauterine pregnancy with a gestational age (GA) of 8 weeks, with a synchronous evolutive adnexal pregnancy of the same GA and some free fluid in the pouch of Douglas. She underwent an urgent laparoscopy which showed an intact gestational sac containing an embryo on the right ovary associated with mild hemoperitoneum. An ovarian wedge resection was performed to preserve ovarian tissue. The intrauterine pregnancy had no complications and the patient delivered vaginally at term. Heterotopic pregnancy is potentially life-threatening. Despite being extremely rare after natural conception, and even more so in the absence of major risk factors, it should be considered in any pregnant woman with abdominal pain. A high index of suspicion is important for a prompt diagnosis, selection of the appropriate surgical treatment and successful obstetric outcomes.
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http://dx.doi.org/10.1016/j.crwh.2019.e00144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833366PMC
October 2019

The role of innate immunity in spontaneous preterm labor: A systematic review.

J Reprod Immunol 2019 11 22;136:102616. Epub 2019 Sep 22.

General Pathology Institute, Faculty of Medicine, University of Coimbra, Portugal.

Background: Immunoinflammatory response by innate immunity components is a field with increasing interest in understanding the mechanisms behind preterm labor (PTL).

Objectives: Systematic review of the role of innate immunity in spontaneous PTL.

Study Design: PubMed, Scopus, ClinicalTrials.gov and Web of Science were searched using pregnancy AND innate OR toll-like OR natural-killer OR dendritic AND delivery OR premature OR rupture of membranes.

Main Outcome Measures: All article titles and abstracts were evaluated by two individuals, based in strict predefined inclusion criteria. For relevant studies, title, abstract, and full text were assessed to identify PTL and innate immunity studies, excluding multiple pregnancies, cervical insufficiency and indicated PTL.

Results: From 894 articles evaluated, 101 full texts articles were assessed independently. For this systematic review 44 studies were finally included. Toll-like receptors 2 and 4 mediated immune dysfunction and inflammation can result in PTL. Moreover, PTL is linked to high levels of CD14 monocytes; neutrophils seem important in inflammation-associated PTL and in pathological preterm premature rupture of membranes. Besides, decidual natural-killer cells and premature activation of dendritic cells may also participate in the etiology of PTL. Finally, dysregulation of maternal complement might increase the risk of PTL, characterized by high levels of innate lymphoid cells 2 and 3.

Conclusions: Further research is warranted to ascertain the precise role of innate immunity in PTL. Nonetheless, our results indicate that Toll-like receptors, monocytes, natural-killer cells, dendritic cells and complement have significant roles in PTL.
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http://dx.doi.org/10.1016/j.jri.2019.102616DOI Listing
November 2019

[Gestational Diabetes Mellitus: Is There an Advantage in Using the Current Diagnostic Criteria?]

Acta Med Port 2018 Aug 31;31(7-8):416-424. Epub 2018 Aug 31.

Serviço de Obstetrícia A. Maternidade Daniel de Matos. Centro Hospitalar e Universitário de Coimbra. Coimbra. Faculdade de Medicina da Universidade de Coimbra. Coimbra. Portugal.

Introduction: There is no international consensus regarding gestational diabetes mellitus diagnostic criteria. In Portugal, the Carpenter and Coustan criteria were replaced by an adaptation of the International Association of Diabetes and Pregnancy Study Groups criteria. Our aim was to compare the incidence and outcomes of pregnancies complicated by gestational diabetes mellitus according to the current and previous criteria.

Material And Methods: Retrospective analysis of 1218 singleton pregnancies complicated with gestational diabetes mellitus, with surveillance/delivery between 2008-2015. Two groups were considered: identification according to the Directorate-General of Health criteria - International Association of Diabetes and Pregnancy Study Groups (group 1); identification through Carpenter and Coustan criteria (group 2). A comparative analysis was performed.

Results: The incidence of gestational diabetes mellitus doubled (9.4% vs 4.6%), and the number of consultations/year increased (~3000 vs ~2000). In Group 1, in comparison with group 2, there was a lower risk of macrosomia in newborns [RR 0.44 (IC (95%):0.26 - 0.76)] and a higher risk of small for gestational age infants [RR 1.99 (IC (95%):1.19 - 3.31)]; a 6 - fold and 4 fold higher risk in neonatal hypoglycemia [RR 6.30 (IC (95%): 3.39 - 11.71)] and hyperbilirubinemia [RR 3.89 (IC (95%): 2.25 - 6.72)] were also observed, respectively. There were no differences regarding other outcomes.

Discussion: Outcomes related to the decrease in macrosomia did now show any improvement, with even an increase in Small for Gestational Age and neonatal complications. Given the increased incidence of gestational diabetes mellitus, Directorate-General of Health - International Association of Diabetes and Pregnancy Study Groups criteria may be associated with greater healthcare-related costs due to more frequent consultations, with no apparent obstetrical/neonatal benefit.

Conclusion: The Directorate-General of Health - International Association of Diabetes and Pregnancy Study Groups criteria were associated with a decrease in macrosomia, not accompanied by an improvement of obstetrical/perinatal outcomes. The benefit of using these criteria is open to debate.
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http://dx.doi.org/10.20344/amp.10135DOI Listing
August 2018

Amniotic membrane extract differentially regulates human peripheral blood T cell subsets, monocyte subpopulations and myeloid dendritic cells.

Cell Tissue Res 2018 08 26;373(2):459-476. Epub 2018 Mar 26.

Blood and Transplantation Center of Coimbra, Portuguese Institute of the Blood and Transplantation, Quinta da Vinha Moura, São Martinho do Bispo, 3041-861, Coimbra, Portugal.

The discovery of the immunoregulatory potential of human amniotic membrane (hAM) propelled several studies focusing on its application for the treatment of immunological disorders. However, there is little information regarding the effects of hAM on distinct activation and differentiation stages of immune cells. Here, we aim to investigate the effect of human amniotic membrane extract (hAME) on the pattern of cytokine production by T cells, monocytes and myeloid dendritic cells (mDCs). For this purpose, peripheral blood mononuclear cells (PBMCs) from eight healthy individuals were stimulated in vitro in the presence or absence of hAME. Mitogen-induced proliferation of PBMCs and cytokine production among the distinct T cell functional compartments, monocyte subpopulations and mDCs were evaluated. hAME displayed an anti-proliferative effect and decreased the frequency of T cells producing tumor necrosis factor (TNF)α, interferon (IFN)γ and interleukin (IL)-2, for all T cell functional compartments. The frequency of IL-17 and IL-9-producing T cells was also reduced. The inhibition of mRNA expression of granzyme B, perforin and NKG2D by CD8 T cells and γδ T cells and the augment of FoxP3 and IL-10 in CD4 T cells and IL-10 in regulatory T cells were also observed. Furthermore, hAME inhibited IFNγ-induced protein (IP)-10 expression by classical and non-classical monocytes, without hampering the production of TNFα and IL-6 by monocytes and mDCs. These results suggest that hAME exerts an anti-inflammatory effect on T cells, still at a different extent for distinct T cell functional compartments.
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http://dx.doi.org/10.1007/s00441-018-2822-1DOI Listing
August 2018

Why could a woman have three Trisomy 21 pregnancies? - a case report.

Clin Case Rep 2017 08 15;5(8):1222-1225. Epub 2017 Jun 15.

Department of Obstetrics and Gynecology A Centro Hospitalar e Universitário de Coimbra Coimbra Portugal.

Mosaicism, an important cause for recurrent T21, should be suspected in families with more than one affected child wishing to receive prenatal counseling. Fluorescence in-situ hybridization analysis in a large number of cells and in different tissue samples is critical for detecting low-level mosaicism and is a key prognostic factor.
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http://dx.doi.org/10.1002/ccr3.997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5538204PMC
August 2017

Acute Onset Neurological Disorders during Pregnancy: A Literature Review.

Rev Bras Ginecol Obstet 2017 Oct 26;39(10):560-568. Epub 2017 Jun 26.

Obstetrics Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

 To characterize the most common peripheral and central neurological disorders during pregnancy.  Original research and review of the literature on neurological complications during pregnancy. We searched for keywords related to the topic on different databases.  Pregnancy involves physiological changes that can trigger peripheral neurological and/or central nervous system pathologies, which can sometimes be associated with hypertensive disorders. A definitive diagnosis of neurological disorders can be made according to the trimester of pregnancy and the clinical findings. Carpal tunnel syndrome and peripheral facial palsy are common peripheral neurological disorders, more frequent in the second half of pregnancy. Central nervous disorders are more complex and a precise diagnosis must be made in order to improve perinatal outcomes, provide correct management and treatment and to prevent acute and long-term complications.  It is possible to achieve a precise diagnosis, management and treatment of neurological disorders during pregnancy, but these require a multidisciplinary approach, crucial to improve perinatal outcomes.
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http://dx.doi.org/10.1055/s-0037-1604058DOI Listing
October 2017

Syphilis in Pregnancy and Congenital Syphilis: Reality in a Portuguese Central University Hospital.

Rev Bras Ginecol Obstet 2017 06 13;39(6):265-272. Epub 2017 Jun 13.

Obstetric Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

 To evaluate maternal-fetal surveillance and follow-up of infants at risk for congenital syphilis (CS).  Retrospective cohort study in a Portuguese Tertiary Referral Hospital. The main inclusion criterion was a positive syphilis serology. The study included all pregnant women that delivered in our hospital between January 2004 and December 2013. The neonates were classified according to their probability of infection based on the Centers for Disease Control and Prevention guidelines.  Among the 27 pregnancies at risk for CS, 48.2% ( = 13) of the women had a diagnosis during the 1st trimester, and the median gestational age at the end of the treatment was 28 weeks. Inadequate treatment was noted in 44.4% ( = 12) of the women. Adverse pregnancy outcomes were observed in 30.8% of the cases ( = 8), 5 of which had been adequately treated. We found 2 (7.7%) cases with "proven or highly probable CS," 10 (38.5%) with "possible CS," 12 (46.1%) with "less likely CS," and 2 (7.7%) with "unlikely CS." Among the infants, the treatment was successful, except for 1 neurosyphilis case.  This study highlights many of the difficulties/concerns encountered in the maternal-neonatal management of syphilis. We highlight the importance of assuring the early detection of the infection as a way of guaranteeing the timely treatment, as well as a good compliance to the treatment and follow-up through a more efficient pregnant women surveillance network.
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http://dx.doi.org/10.1055/s-0037-1603646DOI Listing
June 2017

Induction of labour vs. spontaneous vaginal delivery in twin pregnancy after 36 weeks of gestation.

J Obstet Gynaecol 2017 Jan 7;37(1):29-32. Epub 2016 Dec 7.

a Obstetric A Department , Coimbra Hospital and University Center , Coimbra , Portugal.

Time for delivery and delivery pathway in twin pregnancies are still in great debate. Our study goal was to compare the characteristics of delivery and maternal-foetal outcome in uncomplicated near-term twin pregnancies undergoing labour induction and those with spontaneous labour. We found no statistical differences in patients with twin pregnancies who underwent labour induction and those with spontaneous labour regarding the history of previous caesarean delivery, parity, pregnancy achieved by assisted reproductive techniques (ART), chorionicity and cervical dilation at the admission as well as maternal and neonatal morbidity, and admission to the neonatal intensive care unit. There were significant differences in the caesarean section rate (60.6 vs. 33.3%, p < .05) and the time interval between delivery of the first and second foetus (9.8 vs. 11.7 min, p = .024). There was an increased incidence of caesarean section after the induction of labour. However, it appears to be a safe option.
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http://dx.doi.org/10.1080/01443615.2016.1205554DOI Listing
January 2017

Is Preterm Labor Influenced by the Maternal-Fetal Interface?

Fetal Pediatr Pathol 2017 Apr 9;36(2):89-105. Epub 2016 Nov 9.

c Faculty of Medicine , Institute of Anatomical and Molecular Pathology, University of Coimbra , Portugal Coimbra , Portugal.

Preterm labor (PTL) accounts for almost 11% of deliveries, and is a major cause of neonatal morbidity and mortality. T regulatory (Treg) cells may prevent fetal rejection by the maternal immune system under the influence of progesterone. Case control study was conducted to determine Treg cells, IL-10, TGF-β, and membrane progesterone receptorα (mPRα) in the maternal-fetal interface (placenta), including eight pregnant women with threatened PTL (study group) and 16 normal-delivery women (control group). Comparing study group versus control, mean gestational age of delivery differed significantly (p = 0.02), as did endothelial hyperplasia in the upper half (p = 0.035) and the lower half (p = 0.005) of the placenta. Besides, there was higher expression of mPRα and IL-10 in all layers, while Foxp3 expression occurred equally and only in the decidua. TGF-β expression was similar in both groups. Preterm group placentas showed higher endothelial hyperplasia in both upper and lower halves of the placenta.
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http://dx.doi.org/10.1080/15513815.2016.1242674DOI Listing
April 2017

Monochorionic versus dichorionic twins: Are obstetric outcomes always different?

J Obstet Gynaecol 2016 Jul 25;36(5):598-601. Epub 2016 Mar 25.

a Obstetrics A Unit, Daniel De Matos Maternity, Coimbra Hospital and University Centre , Coimbra , Portugal .

This prospective cohort study compared obstetric, perinatal and postpartum outcomes of monochorionic diamniotic (n = 228) versus (vs.) dichorionic (n = 598) twin pregnancies. Statistical analysis was performed using software SPSS® v19.0.0.2. Chi square, Fischer's exact, Student's t and Mann-Withney tests were applied. Obstetrical complications rates were 85.5% vs. 75.1% (p < 0.01). Differences were found in preterm premature rupture of membranes (26.3% vs. 19.3%, p < 0.05) and intrauterine growth restriction (19.7% vs. 10.5%, p < 0.01). Twin-to-twin transfusion syndrome (TTTS) occurred in 7.9% of monochorionic pregnancies. Vaginal delivery occurred in 47.4% vs. 43.1%. Monochorionic pregnancies had earlier gestational ages at delivery and subsequently lower birthweights (p < 0.01). There was no difference in Apgar scores. Admission rate of at least one of the newborns in intensive care unit (NICU) was 50% vs. 38.9% (p < 0.05). Postpartum complications were similar. These results were the same excluding TTTS cases, except for admission in NICU (46.8% vs. 34.9%, p > 0.05). Analysing only the uncomplicated pregnancies (33 vs. 149), there were no differences in perinatal outcomes. We conclude that monochorionic pregnancies had higher rates of obstetrical complications, which were independent of TTTS occurrence in our sample. However, considering only the uncomplicated pregnancies till delivery, there were no significant differences in perinatal outcomes.
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http://dx.doi.org/10.3109/01443615.2015.1116501DOI Listing
July 2016

Can membrane progesterone receptor α on T regulatory cells explain the ensuing human labour?

J Reprod Immunol 2016 Feb 20;113:22-6. Epub 2015 Oct 20.

Faculty of Medicine, University of Coimbra, Portugal.

Progesterone acts as an immunosteroid by contributing to the establishment of a pregnancy-protective milieu. It seems that it is the responsibility of progesterone to evade the inflammatory events that lead to parturition. T regulatory lymphocytes (Treg cells) could further explain the inhibition of the inflammatory mechanisms that lead to labour through the rapid action of progesterone on this cell subset. We investigated Treg cells and the membrane progesterone receptor α (mPRα) in these immune cells with in relationship to human parturition. This pilot cohort study was conducted in a single-centre tertiary obstetrical unit with 20 normal pregnant women. Variation in the absolute and relative frequency of CD4(+) T cells, Treg cells, and of mPR(α+) Treg cells was calculated by flow cytometry on three occasions (second and third trimesters; delivery day). Our results show that during normal pregnancy there is a generalised increase in Treg cells and mPR(α+) Treg cells, from the second to the third trimesters (23.4% vs. 52.3% and 4.3% vs. 8.3%, respectively). On the contrary, on delivery day, compared with the values in the third trimester, there is a sudden decrease in both Treg cells (52.3% vs. 17.4%) and mPR(α+) Treg cells (8.3% vs. 6.1%). Our findings suggest that human labour may develop as a consequence of a decline in mPR(α+) Treg cells, which reduces progesterone anti-inflammatory action through Treg cells.
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http://dx.doi.org/10.1016/j.jri.2015.10.002DOI Listing
February 2016

Does progesterone administration in preterm labor influence Treg cells?

J Perinat Med 2016 Aug;44(6):605-11

Objectives: The aim of this study was to determine if the actions of progesterone on preterm labor are accomplished through modulation of the percentage of regulatory T-cells (Treg).

Methods: The study was a cohort pilot study made in a single center tertiary obstetrical unit with women in preterm labor arrested with tocolytic treatment. Variation of the number and percentage of Treg cells obtained from peripheral blood samples of women with preterm labor were calculated by flow cytometry, before and after progesterone administration.

Results: In the paired samples for each patient, there was a significant difference in the Treg cell pool after progesterone treatment, with an increase in both their percentage (48.9 vs. 53; P=0.07) and absolute number (14.8 vs. 56.5 cells/μL; P=0.046).

Conclusions: This research demonstrated a considerable increase in the Treg cell pool after progesterone treatment. This indicates a possible mechanism for progesterone treatment benefits in preterm labor, potentially increasing its more rational use.
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http://dx.doi.org/10.1515/jpm-2015-0134DOI Listing
August 2016

Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal.

Rev Bras Ginecol Obstet 2015 May;37(5):241-6

Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal.

Purpose: It was to analyse the most critical areas in Obstetrics and to suggest measures to reduce or avoid the situations most often involved in these disputes.

Methods: Obstetrics cases submitted to the Medico-legal Council since the creation of the National Institute of Legal Medicine and Forensic Sciences in 2001 until 2011 were evaluated. A comprehensive characterization, determination of absolute/relative frequencies, hypothesis of a linear trend over the years and the association between each parameter was done.

Results: The analysis has shown no significantly linear trend. The most common reasons for disputes were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). Perinatal asphyxia showed no significantly linear trend (p=0.58) and was usually related to perinatal deaths or permanent neurologic sequelae in newborn children. Traumatic injuries of the newborn, mostly related to instrumented deliveries, shoulder dystocia or vaginal delivery in breech presentation, has shown a significantly increased linear trend (p<0.001), especially related to instrumented deliveries. The delay/absence of cesarean section was the clinical procedure questioned in a significantly higher number of cases of perinatal asphyxia (68.7%) and of traumatic lesions of the newborn due to instrumented deliveries (20.5%).

Conclusion: It is important to improve and correct theoretical/practical daily clinical performance in these highlighted areas, in order to reduce or even avoid situations that could end up in medico-legal litigations.
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http://dx.doi.org/10.1590/SO100-720320150005304DOI Listing
May 2015

Do induced twin pregnancies influence the obstetric and neonatal results of multiple births born before 32 weeks? Comparison to spontaneous gestation.

Rev Bras Ginecol Obstet 2015 May;37(5):216-21

Department of Obstetrics, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Purpose: To compare obstetric outcomes of induced preterm twin births (under 32 weeks gestation) with those spontaneously conceived.

Methods: Prospective study of twin pregnancies (25 induced and 157 spontaneously conceived) developed over a period of 16 years in a tertiary obstetric center. Demographic factors, obstetric complications, gestational age at delivery, mode of delivery, birth weight and immediate newborn outcome were compared.

Results: The analysis of obstetrical complications concerning urinary or other infections, hypertensive disorders of pregnancy, gestational diabetes, fetal malformations, intrauterine fetal death, intrauterine growth restriction and intrauterine discordant growth reveal no significant statistical differences between the two groups. First trimester bleeding was higher in the induced group (24 versus 8.3%, p=0.029). The cesarean delivery rate was 52.2% in spontaneous gestations and 64% in induced gestations. Gestational age at delivery, birth weight, Apgar scores at first and fifth minutes, admissions to Neonatal Intensive Care Unit and puerperal complications show no statistically significant differences between the two groups. These results were independent of chorionicity and induction method.

Conclusion: The mode of conception did not influence obstetric and neonatal outcomes. Although induced pregnancies have higher risk of first trimester bleeding, significant differences were not observed regarding other obstetric and puerperal complications and neonatal results.
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http://dx.doi.org/10.1590/SO100-720320150005272DOI Listing
May 2015

Low-molecular-weight heparin plus aspirin versus aspirin alone in pregnant women with hereditary thrombophilia to improve live birth rate: meta-analysis of randomized controlled trials.

Arch Gynecol Obstet 2016 Jan 10;293(1):81-86. Epub 2015 Jun 10.

Obstetric Unit, Coimbra University Hospital Centre, Rua Miguel Torga, 3030-165, Coimbra, Portugal.

Purpose: To determine in women with hereditary thrombophilia whether the use of the combination of low-molecular-weight heparin (LMWH) and aspirin (ASA) is better than ASA alone.

Methods: Meta-analysis of randomized controlled trials evaluating LMWH + ASA compared to ASA in pregnant women with hereditary thrombophilia in order to improve live birth rate. A systematic literature search was conducted in 5 databases (PubMed, Cochrane Controlled Trials Register, EMBASE, Scopus and ISI Web of Knowledge). Trial selection, data extraction, and quality assessment were performed independently by two authors. The main outcome measure was live birth rate. Secondary outcomes included rates of first-trimester miscarriage, prematurity, pre-eclampsia, and low birth weight for gestational age babies.

Results: Four trials were included in the quantitative synthesis in a total of 222 randomized women. Effect of LMWH + ASA versus ASA with regard to live births was evaluable in all four randomized controlled trials with a similar overall treatment effect for the therapies OR 1.7 (95 % CI 0.72-4.0) and without heterogeneity (I (2) = 0 %). No significant differences or heterogeneity were observed between groups for secondary outcomes, namely first-trimester miscarriages OR 0.69 (0.22-2.16), prematurity OR 0.99 (0.4-2.08), pre-eclampsia OR 1.49 (0.63-3.5), and small for gestational age babies OR 2.08 (0.96-4.47).

Conclusions: There were no significant differences in live birth weight and other pregnancy outcomes between LMWH + ASA versus ASA. However, these findings were based on few trials presenting methodological limitations. Therefore, there is no evidence to support any incremental benefit of adding LMWH to ASA alone in women with inherited thrombophilia.
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http://dx.doi.org/10.1007/s00404-015-3782-2DOI Listing
January 2016

Triplet pregnancies: perinatal outcome evolution.

Rev Bras Ginecol Obstet 2014 Sep 12;36(9):393-7. Epub 2014 Sep 12.

Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Purpose: To evaluate the obstetric and perinatal outcomes evolution of triplet pregnancies.

Methods: A prospective observational study was conducted in triplet pregnancies delivered over 16 years in a tertiary obstetric center with differentiated perinatal support. Evaluation of demographic factors, obstetric complications, gestational age at delivery, mode of delivery, birth weight and immediate newborn outcome were done over a 16 years period. A global characterization of the sample was performed considering the listed parameters. Variables were categorized in three groups according to year of occurrence: 1996-2000, 2001-2006, 2007-2011, and all parameters were compared.

Results: Of the 33 triplets included, 72.7% resulted from induced pregnancies. All except one patient received prenatal corticosteroids and five received tocolytics. All women delivered prenatally and no significant differences were seen in the mean gestational age at delivery or birth weight towards time. There were three intrauterine fetal deaths. Neonatal immediate outcomes were not significantly different over the years.

Conclusion: Despite remarkable progresses in perinatal and neonatal cares, no noticeable impact in triplet gestations' outcomes was seen, sustaining that triplets should be avoided due to their great risk of prematurity and neonatal morbidities, either by limiting the numbers of embryos transferred or by fetal reduction.
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http://dx.doi.org/10.1590/so100-720320140005066DOI Listing
September 2014

Twins prematurity--the influence of prenatal surveillance.

J Matern Fetal Neonatal Med 2015 Jun 31;28(9):1108-11. Epub 2014 Jul 31.

Obstetrics A Department, Maternidade Dr Daniel de Matos, Centro Hospitalar e Universitário de Coimbra , Portugal .

Objective: To evaluate the influence of the local prenatal surveillance of twin pregnancies in the obstetrical results.

Methods: A prospective cohort study of multiple pregnancies delivered over a period of 16 years in a tertiary centre was conducted. In this study 861 twin pregnancies were included. They were compared for obstetric complications, gestational age at delivery, mode of delivery and birthweight, according to the place of the surveillance.

Results: Of the 861 cases examined, the following obstetric complications were significantly different: metrorrhagia (p = 0.039), infections (p < 0.001), HELLP (p = 0.007), PROMPT (p < 0.001) and fetal death (p = 0.024). The mode of delivery was similar but occurred mostly ≤32 weeks (p < 0.001), the birthweight was mostly <2000 g and occurred more NICU admission (p < 0.001) when surveillance was outside the MPC-MDM.

Conclusion: Our results demonstrate the crucial importance of prenatal surveillance be carried in a differentiated referral centers with specific/strict protocols or the urgent implementation of same protocols in all other places of surveillance, since this straight surveillance greatly reduces the occurrence of prenatal complications, mainly PROMPT, PTD.
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http://dx.doi.org/10.3109/14767058.2014.943660DOI Listing
June 2015

Lessons from a decade of technical-scientific opinions in obstetrical litigation.

J Forensic Leg Med 2014 Jul 2;25:91-4. Epub 2014 May 2.

Coimbra Faculty of Medicine, Coimbra University, Portugal; National Institute of Legal Medicine, Portugal.

The authors aimed to assess the Portuguese circumstances concerning situations of medico-legal dispute in Obstetrics, evaluate the conclusions of technical-scientific opinions and analyze their consequences. The analysis of all cases of Obstetrics medical responsibility examined in Medico-legal Council since the creation of the National Institute of Legal Medicine was performed. Technical-scientific opinions of those files were examined according to the existence of a causal link and of infringement of the 'leges artis'. The most common reasons for dispute in Obstetrics were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). In the technical-scientific opinions of files examined, the existence of a causal link was established in 17.4%, and the infringement of the 'leges artis' was suggested in 15.5% of cases, numbers which have grown significantly over the years and which are particularly relevant in the proceedings of perinatal asphyxia and traumatic lesions of the newborn. In 11% of cases the opinion was inconclusive due to the poor quality of the clinical process sent for analysis. These results highlight the impact that litigation can have on the professional activity and personal lives of obstetricians. It should alert them for the need to better fulfill medical clinical files in order to reduce or avoid medico-legal conflicts, as well as to the fact of the increasing practice of defensive medicine and its consequences in daily clinical routine for doctors and patients.
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http://dx.doi.org/10.1016/j.jflm.2014.04.012DOI Listing
July 2014

Monoamniotic twins discordant for body stalk anomaly.

J Matern Fetal Neonatal Med 2015 Jan 9;28(1):113-5. Epub 2014 Apr 9.

Obstetric Department A, Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.

Body stalk anomaly is a rare malformation. This anomaly in monozygotic twins is extremely unusual. We describe a case of monoamniotic pregnancy discordant for body stalk anomaly diagnosed at 11 weeks. Ultrasound showed a fetus with a large anterior abdominal wall defect, anomaly of the spine and no evidence of lower extremities and other with a normal morphology. As far as our concern, only three monoamniotic pregnancies discordant for this malformation were reported. Our case represents the fourth reported monoamniotic pregnancy discordant for body stalk anomaly with diagnosis made by ultrasound and the second diagnosed in the first trimester.
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http://dx.doi.org/10.3109/14767058.2014.900035DOI Listing
January 2015

Impact of induced pregnancies in the obstetrical outcome of twin pregnancies.

Fertil Steril 2014 Jan 17;101(1):172-7. Epub 2013 Oct 17.

Obstetrics-A Department, Coimbra Hospital and University Center, Coimbra, Portugal; Obstetrical Clinic, Faculty of Medicine, Coimbra University, Coimbra, Portugal.

Objective: To compare obstetric outcomes of induced twins with those spontaneously conceived.

Design: A prospective observational study was conducted in twin pregnancies delivered over 16 years.

Setting: A tertiary obstetric center with differentiated perinatal support.

Patient(s): A total of 180 induced twins and 698 spontaneously conceived were included.

Intervention(s): None.

Main Outcome Measure(s): Comparison of demographic factors, obstetrical complications, gestational age at delivery, mode of delivery, birth weight, and immediate newborn outcome.

Result(s): First-trimester bleeding was higher in the induced group (6.0% vs. 12.2%), as were gestational diabetes (4.4% vs. 8.3%) and discordant intrauterine growth (4.3% vs. 11.1%). Preterm premature rupture of membranes was less frequent (23.9% vs. 12.8%) as was preterm delivery ≤32 weeks (22.5% vs. 14.0%). Cesarean section rate was higher (50.6% vs. 63.9%). Other obstetrical complications, newborn data, and puerperal complications were not statistically different. Except for first-trimester bleeding (significantly associated with monochorionicity), these results were independent from chorionicity. Regarding the induced method (ovulation induction, IVF, or ICSI), IVF is a predictor for first-trimester bleeding and IVF or ICSI a predictor for cesarean section.

Conclusion(s): The higher rates found with induced twins of first-trimester bleeding, gestational diabetes, and discordant growth do not contribute to different neonatal immediate outcomes and do not contribute to higher rates of prematurity, low birth weight, or other major perinatal complications.
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http://dx.doi.org/10.1016/j.fertnstert.2013.09.026DOI Listing
January 2014

Development and validity of a questionnaire to test the knowledge of primary care personnel regarding nutrition in obese adolescents.

BMC Fam Pract 2013 Jul 18;14:102. Epub 2013 Jul 18.

Health Sciences Postgraduate Program, State University of Montes Claros (Unimontes), Montes Claros, MG, Brazil.

Background: In light of its epidemic proportions in developed and developing countries, obesity is considered a serious public health issue. In order to increase knowledge concerning the ability of health care professionals in caring for obese adolescents and adopt more efficient preventive and control measures, a questionnaire was developed and validated to assess non-dietitian health professionals regarding their Knowledge of Nutrition in Obese Adolescents (KNOA).

Methods: The development and evaluation of a questionnaire to assess the knowledge of primary care practitioners with respect to nutrition in obese adolescents was carried out in five phases, as follows: 1) definition of study dimensions 2) development of 42 questions and preliminary evaluation of the questionnaire by a panel of experts; 3) characterization and selection of primary care practitioners (35 dietitians and 265 non-dietitians) and measurement of questionnaire criteria by contrasting the responses of dietitians and non-dietitians; 4) reliability assessment by question exclusion based on item difficulty (too easy and too difficult for non-dietitian practitioners), item discrimination, internal consistency and reproducibility index determination; and 5) scoring the completed questionnaires.

Results: Dietitians obtained higher scores than non-dietitians (Mann-Whitney U test, P < 0.05), confirming the validity of the questionnaire criteria. Items were discriminated by correlating the score for each item with the total score, using a minimum of 0.2 as a correlation coefficient cutoff value. Item difficulty was controlled by excluding questions answered correctly by more than 90% of the non-dietitian subjects (too easy) or by less than 10% of them (too difficult). The final questionnaire contained 26 of the original 42 questions, increasing Cronbach's α value from 0.788 to 0.807. Test-retest agreement between respondents was classified as good to very good (Kappa test, >0.60).

Conclusion: The KNOA questionnaire developed for primary care practitioners is a valid, consistent and suitable instrument that can be applied over time, making it a promising tool for developing and guiding public health policies.
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http://dx.doi.org/10.1186/1471-2296-14-102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733686PMC
July 2013

Antenatal manifestations of mitochondrial disorders.

J Inherit Metab Dis 2013 Sep 30;36(5):805-11. Epub 2013 Jan 30.

Obstetric Unit, University Hospital of Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.

Mitochondrial respiratory chain diseases are a heterogeneous group of pathologies caused by genetic alterations affecting mitochondrial energy production. Theoretically, this deficiency may lead to any symptoms, in any organ or tissue, at any age even before birth. The aim of our study was to identify the frequency and characterize antenatal manifestations identifying possible associations between mitochondrial disease and more specific and earlier manifestation. We retrospectively review the files of 44 paediatric subjects with genetic and biochemical alterations of respiratory chain identified in the first decade of life and compare data with a control group (n = 88). Our results show that maternal age was similar in both groups. The female gender was predominant in patients group. Gestational age at delivery was similar in both groups. Concerning birth weight, it was significantly lower (p = 0.001) in patients (2899.9 ± 538.3 vs. 3246.6 ± 460.2 g). Fifteen pregnancies of the patients group were considered abnormal. Our findings show that intrauterine growth restriction was the most frequent antenatal feature observed. Neonatal morbidity was significantly higher (fivefold) in patients (p < 0.001). The clinical findings are independent of the molecular defect type. Our results are preliminary and more studies are needed, in order to learn more about mitochondrial physiology and activity in embryological development for the assessment of mitochondrial disease progress in fetal life. However, the present work is a significant contribution, given the scarcity of information in this field.
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http://dx.doi.org/10.1007/s10545-012-9567-xDOI Listing
September 2013

[Vaccines and pregnancy].

Acta Med Port 2011 Dec 31;24 Suppl 4:1063-8. Epub 2011 Dec 31.

Maternidade Dr Daniel de Matos - Serviço de Obstetrícia, Hospitais da Universidade de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

Routine vaccination is part of the pediatrics universe. In adulthood and particularly when women voluntarily access to medical care, immunization should be reviewed and updated. There are many doubts that generate in all health professionals anxiety and concern about the vaccination of a pregnant woman. This article aims to describe the immunological changes in pregnant women, to clarify the purpose of immunization during pregnancy, and to enumerate indications, contraindications and risks of vaccines of the Portuguese National Vaccine Plane and other vaccines against diseases with prevalence in other countries. Due to the medical and social impact of vaccination against seasonal influenza and influenza A (H1N1) in the winter of 2009, during an influenza (H1N1) pandemic flu, we make reference to the indications and vaccination against these infections in pregnancy.
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December 2011

[Cytomegalovirus: is there a place for screening during pregnancy?].

Acta Med Port 2011 Dec 31;24 Suppl 4:1003-108. Epub 2011 Dec 31.

Serviço de Obstetrícia, Maternidade Dr Daniel de Matos, Hospitais da Universidade de Coimbra, Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal.

The maternal and fetal/congenital infection by cytomegalovirus (CMV) during pregnancy is the leading infectious cause of neurologic impairment and hearing loss. CMV screening during pregnancy has been widely discussed for several years, but still no consensus has been established. Most developed countries do not recommend it because the majority of infected fetuses will be free of any symptom, and there is currently no reliable knowledge about fetal and neonatal prognosis and also due to lack of valid, effective and safe treatment during fetal life. The aims of this review are to discuss the physiopathology of maternal and fetal infection by CMV, the diagnosis and possible treatments, as well as to determine the usefulness of a systematic screening during pregnancy.
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December 2011

Acute kidney injury in pregnancy: a clinical challenge.

J Nephrol 2012 Jan-Feb;25(1):19-30

Nephrology Department, Coimbra's University Hospitals, Coimbra, Portugal.

The incidence of acute kidney injury in pregnancy declined significantly over the second half of the 20th century; however, it is still associated with major maternal and perinatal morbidity and mortality. A set of systemic and renal physiological adaptive mechanisms occur during a normal gestation that will constrain several changes in laboratory parameters of renal function, electrolytes, fluid and acid-base balances. The diagnosis of acute kidney injury in pregnancy is based on the serum creatinine increase. The usual formulas for estimating glomerular filtration rate are not validated in this population. During the first trimester of gestation, acute kidney injury develops most often due to hyperemesis gravidarum or septic abortion. In the third trimester, the differential diagnosis is more challenging for the obstetrician and the nephrologist and comprises some pathologies that are reviewed in this article: preeclampsia/HELLP syndrome, acute fatty liver of pregnancy and thrombotic microangiopathies.
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http://dx.doi.org/10.5301/jn.5000013DOI Listing
June 2012

Antenatal diagnosis of congenital hepatic hemangioma: a case report.

Cases J 2009 Aug 7;2:6829. Epub 2009 Aug 7.

Obstetrics Department of University Hospital of Coimbra, Rua Miguel Torga, 3030-165, Coimbra, Portugal.

Hepatic tumors in children account for only 1 to 5% of all pediatric tumors. Hepatic hemangioma is, however, the third most common tumor of the liver in childhood. We report a case of an antenatal diagnosis of a hepatic tumor detected on a first obstetric ultrasound, at 26(th) week of gestation. It revealed a complex, predominantly solid hepatic lesion with 3 x 3 cm and a marked, essentially peripheral, Doppler blood flow. Fetal echocardiography showed a normal heart besides a vena cava displacement by the hepatic mass. Fetal Hepatic hemangioma was suspected. Follow-up ultrasounds were unchanged. Pregnancy evolved well. At 36 weeks of gestation was spontaneously delivered a 3300 g boy whose examination revealed a visible thoracoabdominal circulation and a palpable liver. No skin lesions, namely hemangiomas or petechiae were identified. Postnatal magnetic resonance imaging confirmed the diagnosis of Hepatic hemangioma. Treatment was initiated with prednisolone followed by interferon. After 2 years, there is no active lesion.
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http://dx.doi.org/10.4076/1757-1626-2-6829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769318PMC
August 2009

Should apparently uncomplicated monochorionic twins be delivered electively at 32 weeks?

J Matern Fetal Neonatal Med 2009 Nov;22(11):1077-80

Obstetrics Department, Coimbra University Hospitals, Coimbra, Portugal.

Objectives: We aimed to estimate the optimal time of delivery and investigated the residual risk of fetal death after viability in otherwise uncomplicated monochorionic diamniotic twin pregnancies.

Study Design: A database of 576 completed multiple pregnancies that were managed in our tertiary referral fetal medicine department between 1996 and 2007 was reviewed and the uncomplicated 111 monochorionic and the 290 dichorionic diamniotic twin pregnancies delivered after 24 weeks were selected. The rate of fetal death was derived for two-week periods starting at 24 weeks' gestation and the prospective risk of fetal death was calculated by determining the number of intrauterine fetal deaths that occurred within the two-week block divided by the number of continuing uncomplicated monochorionic twin pregnancies during that same time period.

Results: The unexpected single intrauterine deaths rate was 2.7% versus 2.8% in previously uncomplicated monochorionic and dichorionic diamniotic pregnancies, respectively. The prospective risk of unexpected stillbirth after 32 weeks of gestation was 1.3% for monochorionic and 0.8% for dichorionic pregnancies.

Conclusions: In otherwise apparently uncomplicated monochorionic diamniotic pregnancies this prospective risk of fetal death after 32 weeks of gestation is lower than reported and similar to that of dichorionic pregnancies, so does not sustain the theory of elective preterm delivery.
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http://dx.doi.org/10.3109/14767050903042579DOI Listing
November 2009