Objective To evaluate the expulsion and continuation rates of the copper intrauterine device (IUD) inserted in the immediate postpartum period in a Brazilian public university hospital. Materials and Methods In the present cohort study, we included women who received immediate postpartum IUD at vaginal delivery or cesarean s March 2018 to December 2019. Clinical data and the findings of transvaginal ultrasound (US) scans performed 6-weeks postpartum were collected. The expulsion and continuation rates were assessed 6-months postpartum using data from the electronic medical records or by telephone contact. The primary outcome was the proportion of IUDs expelled at 6 months. For the statistical analysis, we used the Student t-test, the Poisson distribution, and the Chi-squared test. Results There were 3,728 births in the period, and 352 IUD insertions were performed, totaling a rate of 9.4%. At 6 weeks postpartum, the IUD was properly positioned in 65.1% of the cases, in 10.8% there was partial expulsion, and in 8.5% it had been completely expelled. At 6 months postpartum, information was obtained from 234 women, 74.4% of whom used IUD, with an overall expulsion rate of 25.6%. The expulsion rate was higher after vaginal delivery when compared with cesarean section (68.4% versus 31.6% respectively; p = 0.031). There were no differences in terms of age, parity, gestational age, final body mass index, and newborn weight. Conclusion Despite the low insertion rate of copper IUDs in the postpartum period and a higher expulsion rate, the rate of long-term continuation of intrauterine contraception was high, indicating that it is a useful intervention to prevent unwanted pregnancies and to reduce short-interval birth.

Objective To evaluate the association between pain intensity in the active phase of the first stage of labor with the use or not of nonpharmacological methods for pain relief in a real-life scenario. Methods This was an observational cross-sectional study. The variables analyzed were obtained by a questionnaire with the mothers (up to 48 hours postpartum) to investigate the intensity of pain during labor using the visual analog scale (VAS). The nonpharmacological pain relief methods routinely used in obstetric practice were evaluated by consulting medical records. The patients were separated into two groups: Group I – patients who did not use nonpharmacological methods for pain relief and Group II –patients who used these methods. Results A total of 439 women who underwent vaginal delivery were included; 386 (87.9%) used at least 1 nonpharmacological method and 53 (12.1%) did not. The women who did not use nonpharmacological methods had significantly lower gestational age (37.2 versus 39.6 weeks, p < 0.001) and shorter duration of labor (24 versus 114 min, p < 0.001) than those who used the methods. There was no statistically significant difference in the pain scale score using the VAS between the group that used nonpharmacological methods and the group that did not (median 10 [minimum 2–maximum 10] versus 10 [minimum 6–maximum 10] p = 0.334). Conclusion In a real-life setting, there was no difference in labor pain intensity between the patients who used nonpharmacological methods and those who did not use them during the active phase of labor.

Objective Systemic lupus erythematosus (SLE) may cause irreversible organ damage. Pregnancy with SLE may have severe life-threatening risks. The present study aimed to determine the prevalence of severe maternal morbidity (SMM) in patients with SLE and analyze the parameters that contributed to cases of greater severity.Methods This is a cross-sectional retrospective study from analysis of data retrieved from medical records of pregnant women with SLE treated at a University Hospital in Brazil. The pregnant women were divided in a control group without complications, a group with potentially life-threatening conditions (PLTC), and a group with maternal near miss (MNM). Results The maternal near miss rate was 112.9 per 1,000 live births. The majority of PLTC (83.9%) and MNM (92.9%) cases had preterm deliveries with statistically significant increased risk compared with the control group (p = 0.0042; odds ratio [OR]: 12.05; 95% confidence interval [CI]: 1.5–96.6 for the MNM group and p = 0.0001; OR: 4.84; 95%CI: 2.2–10.8 for the PLTC group). Severe maternal morbidity increases the risk of longer hospitalization (p < 0.0001; OR: 18.8; 95%CI: 7.0–50.6 and p < 0.0001; OR: 158.17; 95%CI: 17.6–1424,2 for the PLTC and MNM groups, respectively), newborns with low birthweight (p = 0.0006; OR: 3.67; 95%CI: 1.7–7.9 and p = 0.0009; OR: 17.68; 95%CI: 2–153.6) for the PLTC and MNM groups, respectively] as well as renal diseases (PLTC [8.9%; 33/56; p = 0.0069] and MNM [78.6%; 11/14; p = 0.0026]). Maternal near miss cases presented increased risk for neonatal death (p = 0.0128; OR: 38.4; 95%CI: 3.3–440.3]), and stillbirth and miscarriage (p = 0.0011; OR: 7.68; 95%CI: 2.2–26.3]). Conclusion Systemic lupus erythematosus was significantly associated with severe maternal morbidity, longer hospitalizations, and increased risk of poor obstetric and neonatal outcomes.

Physical and emotional burdens during the journey of infertile people through assisted reproductive technologies are sufficient to justify the efforts in developing patient-friendly treatment strategies. Thus, shorter duration of ovarian stimulation protocols and the need for less injections may improve adherence, prevent mistakes, and reduce financial costs. Therefore, the sustained follicle-stimulating action of corifollitropin alfa may be the most differentiating pharmacokinetic characteristic among available gonadotropins. In this paper, we gather the evidence on its use, aiming to provide the information needed for considering it as a first choice when a patient-friendly strategy is desired.

Objective Pain is the primary limitation to performing hysteroscopy. We aimed to evaluate the predictive factors of low tolerance to office hysteroscopic procedures. Methods Retrospective cohort study of the patients who underwent office hysteroscopy from January 2018 to December 2020 at a tertiary care center. Pain tolerance to office-based hysteroscopy was subjectively assessed by the operator as terrible, poor, moderate, good, or excellent. Categorical variables were compared with the use of the Chi-squared test; an independent-samples t-test was conducted to compare continuous variables. Logistic regression was performed to determine the main factors associated with low procedure tolerance. Results A total of 1,418 office hysteroscopies were performed. The mean age of the patients was 53 ± 13.8 years; 50.8% of women were menopausal, 17.8% were nulliparous, and 68.7% had a previous vaginal delivery. A total of 42.6% of women were submitted to an operative hysteroscopy. Tolerance was categorized as terrible or poor in 14.9% of hysteroscopies and moderate, good, or excellent in 85.1%. A terrible or poor tolerance was more frequently reported in menopausal women (18.1% vs. 11.7% in premenopausal women, p = 0.001) and women with no previous vaginal delivery (18.8% vs. 12.9% in women with at least one vaginal birth, p = 0.007). Low tolerance led more often to scheduling a second hysteroscopic procedure under anesthesia (56.4% vs. 17.5% in reasonable-to-excellent tolerance, p < 0.0005). Conclusion Office hysteroscopy was a well-tolerated procedure in our experience, but menopause and lack of previous vaginal delivery were associated with low tolerance. These patients are more likely to benefit from pain relief measures during office hysteroscopy.

As part of the celebration of the National Cancer Awareness Day (November 27), the launch of the 2023 estimate of the incidence of cancer in Brazil was on November 23, 2022 at the headquarters of the National Cancer Institute (INCA) in Rio de Janeiro, including the 21 most frequent tumors in the country. The estimate is an important planning and management tool in oncology in Brazil and provides fundamental information for the definition of public policies.[1] During the three-year period (2023–2025), of the total of 704,000 new cases of cancer each year in the country, excluding non-melanoma skin cancer, an estimated 244,000 occur in women and 239,000 in men. Regarding regions, 70% of cases are expected for the South and Southeast regions. Breast cancer in women (South: 71.44/100 thousand; Southeast: 84.46/100 thousand), prostate cancer (South: 57.23/100 thousand; Southeast: 77.89/100 thousand) and colon and rectum (South: 26.46/100 thousand; Southeast: 28.75/100 thousand) are the three most frequent types in these two regions.[1] [2] In the North and Northeast regions, prostate cancer (North: 28.40/100 thousand; Northeast: 73.28/100 thousand) is the most frequent, followed by female breast cancer (North: 24.99/100 thousand; Northeast: 52.20/100 thousand) and cervical cancer (North: 20.48/100 thousand; Northeast: 17.59/100 thousand). In the Midwest region, prostate cancer has an estimated risk of 61.60/100 thousand and is the type that most affects the population, followed by female breast cancer (57.28/100 thousand) and colorectal cancer (17.08/100 thousand).[1] [2] In relation to the 2023–2025 estimate per year of gynecological cancers specifically, the most frequent are breast cancer 73,610 (30.1%), cervical cancer 17,010 (7.0%), endometrial cancer 7,840 (3.2%) and ovarian cancer 7,310 (3.0%). Estimates for vaginal and vulvar cancers are not available probably given their lower frequency.[2] When comparing with previous estimates (2020–2022) per year of gynecological cancers, there was an increase in the incidence of breast cancer, which was 66,280 (29.7%), of cervical cancer 16,590 (7.4%), endometrial cancer 6,540 (2.9%) and ovarian cancer 6,650 (3.0%). These may be a reflection of the pandemic as, according to Marques et al. (2021),[3] the pandemic period drastically reduced the diagnosis of new cases of cancer in Brazil, possibly given the restrictive measures, including limited consultations in public health services. Regardless of the difficulties caused by the pandemic, it is important to emphasize that the most frequent gynecological cancers, i.e., breast and cervical cancer, are traceable with consolidated methods such as mammography and oncotic colpocytology/molecular human papillomavirus (HPV) tests, respectively. However, regional socioeconomic disparities result in limitations of access to health services that prevent poor women from being screened, diagnosed and treated. I emphasize that cervical cancer is a preventable, curable disease with high morbidity and mortality among women in countries without organized prevention programs, such as Brazil. Globally, more than 600,000 new cases appear each year. In August 2020, the World Health Organization (WHO) launched the “Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem” based on three pillars: 1) ensure that 90% of girls receive the HPV vaccine by the age of 15; 2) ensure that 70% of women undergo a screening exam with an HPV test by age 35 and another by age 45; and 3) that 90% of women identified with precursor lesions or invasive cancer receive treatment.[4] [5] If targets are met, 2 million deaths will be prevented in low- and middle-income countries by 2040.[6] [7] Regarding endometrial cancer, the most common gynecological cancer in medium and high socioeconomic development countries, there was an increase in absolute numbers. There is no screening method for endometrial cancer and its risk factors are obesity and a sedentary lifestyle, in addition to diabetes, menarche at an early age, nulliparity, chronic anovulation, late menopause and the use of tamoxifen. Prevention measures such as maintaining weight and physical activity can significantly reduce its risk. Regarding genetic risk, ∼3% of endometrial carcinomas and 5% of cases in women aged under 70 years are predisposed due to hereditary determinants, and these women must be identified, guided and cared for.[8] In relation to ovarian cancer, no single or combined screening strategy has been adequate so far. Family history is the most important risk factor. Other risk factors include reproductive history such as early menarche and late menopause, the use of drugs for the treatment of sterility, hormone therapy after menopause, among others. In addition, there is the hereditary issue, that is, a mutation in the BRCA1 gene confers an estimated risk of 40–50% of developing ovarian cancer up to 70 years of age and the estimate is of 10–20% if the mutation occurs in the BRCA2 gene.[9] Finally, with effective primary and secondary prevention such as lifestyle changes, the HPV vaccine (prevention of induced HPV cancers) and adequate population coverage of screening methods, these rates will decrease significantly. Furthermore, the identification of cancer with a hereditary pattern allows that cancer risk reduction strategies are adopted for patients and their families. Article published online: 06 March 2023 © 2023. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

The National Specialized Commission on Ultrasonography in GO of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) endorses this document. The production of content is based on scientific evidence on the proposed theme and the results presented contribute to clinical practice. Article published online: 06 March 2023 © 2023. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To evaluate the rates of precancerous lesions, colposcopy referral, and positive predictive value (PPV) by age groups of a population-based screening with DNA-HPV testing. Methods The present demonstration study compared 16,384 HPV tests performed in the first 30 months of the program with 19,992 women tested in the cytology screening. The colposcopy referral rate and PPV for CIN2+ and CIN3+ by age group and screening program were compared. The statistical analysis used the chi-squared test and odds ratio (OR) with 95% confidence interval (95%CI). Results The HPV tests were 3.26% positive for HPV16-HPV18 and 9.92% positive for 12 other HPVs with a 3.7 times higher colposcopy referral rate than the cytology program, which had 1.68% abnormalities. Human Papillomavirus testing detected 103 CIN2, 89 CIN3, and one AIS, compared with 24 CIN2 and 54 CIN3 detected by cytology (p < 0.0001). The age group between 25 and 29 years old screened by HPV testing had 2.4 to 3.0 times more positivity, 13.0% colposcopy referral, twice more than women aged 30 to 39 years old (7.7%; p < 0.0001), and detected 20 CIN3 and 3 early-stage cancer versus 9 CIN3 and no cancer by cytology screening (CIN3 OR= 2.10; 95%CI: 0.91–5.25; p = 0.043). The PPV of colposcopy for CIN2+ ranged from 29.5 to 41.0% in the HPV testing program. Conclusion There was a significant increase in detections of cervix precancerous lesions in a short period of screening with HPV testing. In women < 30 years old, the HPV testing exhibited more positivity, high colposcopy referral rate, similar colposcopy PPV to older women, and more detection of HSIL and early-stage cervical cancer.

In 2020, Brazil and the whole world faced the COVID-19 pandemic, which caused a high number of deaths. This disease was particularly severe for pregnant and postpartum women and determined a significant increase in the Maternal Death Ratio (MMR). To face the disease and assist health professionals in the qualification of the best care to the maternal-fetal binomial, the Ministry of Health and Febrasgo developed a working group formed by professors and researchers from several universities who worked to establish recommendations for the care of pregnant women and puerperal women by the time of the COVID-19 pandemic. In 2022, while we are still experiencing the COVID-19 pandemic, we are surprised by another disease caused by a virus that has been alarming the population and worrying public health authorities and gynecology and obstetrics societies in Brazil and worldwide. It is the infection that is caused by monkeypox virus (MPXV), which is still a not well-known disease, with many of its characteristics not well determined. The knowledge of this disease is fundamental for health professionals working in Obstetrics to plan forms of prevention, as well as the establishment of the diagnosis and treatment of the monkeypox (MPX) disease, preserving the health of the maternal-perinatal binomial. For this reason, the Brazilian Ministry of Health requested the same working group that acted diligently by the time of COVID-19 to establish recommendations for facing MPX, to provide adequate care for pregnant women and puerperal women. These recommendations, based on the knowledge that exists so far, are what guide these orientations and may change depending on new findings that may be presented over time. The MPXV was named after being identified in laboratory monkeys in 1958. The first case of this virus in humans was recorded in 1970 in a child in Congo and since then has become an endemic disease in West and Central Africa.[1] In 2003, the first cases were registered outside the African continent, in the United States,[2] [3] [4] but that was contained through hygienic measures and stock vaccines. In 2017, there was a major outbreak started in Nigeria and spread to some African countries. In early May 2022, another outbreak of MPXV was identified, this time in several countries outside the African continent, with fast dissemination of cases. As a result, on May 21, 2022, the World Health Organization (WHO) declared the existence of an emerging global outbreak of MPXV infection, and on July 23 has determined that this outbreak constituted a Public Health emergency of international concern. Pregnant women present clinically with similar characteristics to nonpregnant women, but may evolve with greater severity, being therefore considered a risk group. In addition to maternal clinical repercussions, there are also concerns specific to the pregnancy period, such as fetal vitality, the possibility of vertical transmission and perinatal outcome. It has been verified that MPXV infection can lead to adverse results in pregnancy, such as fetal death and spontaneous abortion.[5] [6] A recent publication on the evolution of pregnancy in 4 MPXV-infected women showed spontaneous 1^st trimester abortion in 2 pregnant women, without testing of the conception products; an intrauterine death in the 2^nd trimester, with clinical, histological and laboratory evidence of intrauterine fetal infection evidencing the very probable vertical transmission of the disease, and a pregnant woman with MPXV infection that evolved with full-term delivery of healthy conceptus.[7] Close and prolonged skin-to-skin contact, including during sexual activity, seems to be the main means of transmission of MPXV. There are suspicions of transmission of this virus by droplets and aerosols. There is also transmission through biting of rodent animals or even the ingestion of those animals. In addition, contagion by phositis, especially used clothing, can transmit the disease. The quick identification and isolation of affected individuals is fundamental to prevent the spreading of the disease.[8] Transmission of MPXV occurs in the phase of active skin lesions and only ends when they heal completely, which usually requires isolation of 21 to 28 days.[7] [9] [10] There are doubts as to whether the contagion could be prior to the phase of skin lesions, since viral DNA has already been identified in the blood and respiratory system of patients prior to the lesions.[5] [7] Sexual transmission has been discussed not only by contact, but also because the virus has been identified in seminal material.[5] [11] Patients with MPXV should be isolated in a separate area of their home or in hospital services, especially if they present extensive lesions and/or respiratory symptoms. Skin lesions should be covered (for example, with the use of long sleeves and trousers) to minimize the risk of contact. Everyone should wear a face mask in the presence of an infected person. Sexual abstinence is also recommended in the phase of unhealed lesions and condom use for any form of sexual act (anal, oral, or vaginal) in the 12 weeks following the healing of the lesions.[7] Most patients with MPXV will have mild disease and can be cared for at home, where they should remain isolated. Standard cleaning and disinfection procedures should be performed, taking care of clothes and used objects. The diagnosis of infection can be made by anamnesis and clinical findings, with epidemiological suspicion. The incubation period is, on average, 6 to 13 days, and can be from 5 to 21 days. Next to this, a prodromal period occurs, when fever, sweating, headache, myalgia, fatigue and lymphadenomegaly, which is quite characteristic of the disease, are manifested. About 1 to 3 days later, the rash, which usually affects the face, genitals, and extremities, and has a centrifugal character, appears. The lesion evolves from macules to papules, vesicles, pustules...

Objective To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia. Methods Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded. Results Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group. Conclusion Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.

Objective The present review aimed to synthesize the evidence regarding mercury (Hg) exposure and hypertensive disorders of pregnancy (HDP). Data Sources The PubMed, BVS/LILACS, SciELO and UFRJ's Pantheon Digital Library databases were systematically searched through June 2021. Study Selection Observational analytical articles, written in English, Spanish, or Portuguese, without time restriction. Data Collection We followed the PICOS strategy, and the methodological quality was assessed using the Downs and Black checklist. Data Synthesis We retrieved 77 articles, of which 6 met the review criteria. They comprised 4,848 participants, of which 809 (16.7%) had HDP and 4,724 (97.4%) were environmentally exposed to Hg (fish consumption and dental amalgam). Mercury biomarkers evaluated were blood (four studies) and urine (two studies). Two studies found a positive association between Hg and HDP in the group with more exposure, and the other four did not present it. The quality assessment revealed three satisfactory and three good-rated studies (mean: 19.3 ± 1.6 out 28 points). The absence or no proper adjustment for negative confounding factor, such as fish consumption, was observed in five studies. Conclusion We retrieved only six studies, although Hg is a widespread toxic metal and pregnancy is a period of heightened susceptibility to environmental threats and cardiovascular risk. Overall, our review showed mixed results, with two studies reporting a positive association in the group with more exposure. However, due to the importance of the subject, additional studies are needed to elucidate the effects of Hg on HDP, with particular attention to adjusting negative confounding.

Gestational diabetes mellitus (GDM)is an entity with evolving conceptual nuances that deserve full consideration. Gestational diabetes leads to complications and adverse effects on the mother's and infants' health during and after pregnancy. Women also have a higher prevalence of urinary incontinence (UI) related to the hyperglycemic status during pregnancy. However, the exact pathophysiological mechanism is still uncertain. We conducted a narrative review discussing the impact of GDM on the women's pelvic floor and performed image assessment using three-dimensional ultrasonography to evaluate and predict future UI.

Although rare, vaginal agenesis is a relevant condition for gynecologists, who must be familiar with its current treatment. It results from agenesis of the Mullerian ducts, known as Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS), and the incidence is 1:5000 women. In this congenital malformation, genetic alterations affect the development of Mullerian ducts during the embryonic period and there is complete absence or significant hypoplasia of the uterus and vagina, with normal development of the external genitalia and breasts. More rarely, the absence of the uterus and vagina is identified in patients with 46, XY Disorders of Sex Development (DSD) in which the presence of anti-Mullerian hormone inhibits the formation of the Mullerian ducts. In complete androgen insensitivity (Morris syndrome), the absence of testosterone action on its receptors leads to female differentiation of the external genital organs, and the conversion of testosterone to estrogen in peripheral tissues leads to the development of breasts at puberty. The clinical picture is similar to that of Rokitansky Syndrome, and in most cases, this is the initial diagnosis. The gynecologist will differentiate one from the other; in some cases, the suspicion is based on the lack of pubic and axillary hair and/or the presence of palpable gonads in the inguinal canal, but is confirmed by elevated levels of testosterone and the karyotype. Treatment will be the same as that of Rokitansky's syndrome, except for the recommendation to evaluate the gonads, given the higher risk of developing gonadoblastoma. The current recommendation is to wait for the end of puberty to consider gonadectomy, so that secondary characteristics can develop without the need for hormone replacement therapy.[1] As soon as the diagnosis is confirmed, the treatment of vaginal agenesis involves the steps established by the American College of Obstetricians and Gynecologists (ACOG). It begins by informing and advising the patient and her family about the condition, options and timing of treatment, and explaining about sexual relationships and reproductive future. It also involves referrals to psychological support and encouraging participation in support groups.[1] The approach regarding the formation of the neovagina is well established. The time to perform it is decided by the woman, when she manifests the desire to start a sexual relationship and demonstrates maturity and motivation to understand and participate in treatment, which generally occurs at the end of adolescence. Individual aspects inherent to this decision must be considered, such as the family context, religion and sexual orientation. Since 2006, the ACOG recommends that “Nonsurgical creation of the vagina is the appropriate first-line approach in most patients”.[2] This approach is based on a success rate greater than 90%, which is similar to surgery, although with unquestionably smaller morbidity and costs.[1] [3] Dilation is performed by the patient at home, on a daily basis, after detailed guidance from the gynecologist and supervision and follow-up throughout the process. Monitoring with a specialized physiotherapist is always beneficial, and essential when hypertonicity of the pelvic floor muscles is identified. In Brazil, it is difficult to acquire rigid dilators, which are made of resistant material such as polylactic acid, since they are not commercially available in the country. Adapted devices such as acrylic candles and silicone dilators are commonly used. The use of Additive Manufacturing (AM) technology and the three-dimensional printing device (3D Printer) have shown great potential for contribution and innovation in the health area. The 3D printer can create an object through its digital design. The model is evaluated and recognized by the three-dimensional printing device (3D Printer) through Computer Aided Manufacturing (CAM), the software that performs the processes of reading, analysis and digital slicing. Additive manufacturing technology is based on the deposition of layers to build the physical object.[4] The high customization capacity and the possibility of creating prototypes quickly, as well as the production of objects with complex geometries, have enabled the use of this technology in the development of products in the medical field. Additive manufacturing is also an economically viable technology in the production of small batches of customized products compared to conventional methods, making it an interesting alternative in the production and research of customized products.[4] According to a study by Fernandes et al.[5] published in the current issue, the application of this technology in the production of dilators for vaginal agenesis proved to be effective, economically viable, accessible and reproducible. Therefore, dilators can be produced in a gynecological care service equipped with a 3D printer and a qualified professional, allowing women with vaginal agenesis to have access to the recommended treatment for their condition. In addition to women with agenesis, these molds can also be used in other conditions in which dilation may be necessary, such as strictures and shortening of the vagina after radiotherapy or surgery. There is also the possibility of using it in the manufacture of other devices in Urogynecology, such as customized pessaries for the treatment of genital prolapse and urinary incontinence. The use of 3D printing technology reveals the importance of combining knowledge in the field of technology and health, as it enables the development of products with direct impact on medical treatment, in addition to opening up promising perspectives in other areas of Gynecology. Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted...

The National Commission Specialized in Venous Thromboembolism and Hemorrhage in Women of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) endorses this document. The production of content is based on scientific evidence on the proposed theme and the results presented contribute to clinical practice. Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective Although obesity can result in high morbidity and mortality in surgical outcomes because of multiple comorbidities, determinants of outcome in obese patients who underwent endometrial cancer surgery remain unclear. The aim of this study is to assess the relationship between body mass index (BMI) and surgical outcomes in obese patients with endometrial cancer. Methods An institutional retrospective review of the demographic details, clinical characteristics, and follow-up data of 142 patients with endometrial cancer who underwent surgery during a 72-month period was performed. The patients were divided into three groups based on their BMI; patients with BMI < 25 were identified as normal weight, patients with BMI between 25 and 30 were accepted as overweight, and those with BMI ≥ 30 kg/m² were identified as obese. The groups' demographic and clinical variables were compared. Results Of the 142 patients, 42 were in the normal weight group, 55 in the overweight group, and 45 in the obese group. Age, surgical procedures, blood loss, preoperative health status, and metastatic lymph nodes did not show a significant difference between groups. However, surgery time and total lymph nodes were higher in the obese group. (p = 0.02, p = 0.00, and p = 0.00, respectively). Common complications were anemia, fever, intestinal injury, deep vein thrombosis, fascial dehiscence and urinary infection. There was no significant difference according to the complications. Conclusion Our results indicated that higher BMI was significantly associated with a longer duration of endometrial cancer surgery. Minimally invasive surgeries and conventional laparotomy could be performed safely in obese patients. S. O. and G. O. D. designed the study. S. O. and G. O. D. collected the data. S. O. analyzed and interpreted the data. G. O. D. drafted the manuscript. All authors were comprehensively involved in all aspects of the study and in the preparation of the manuscript. All authors have read and approved the final version of the it. Received: 22 May 2022 Accepted: 02 September 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide. Methods This is a review of the literature published in the 21^st century on commercial surrogacy. Results A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers. Conclusion Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated. Objetivo A gestação de substituição é o processo no qual uma mulher engravida e entrega um bebê a outra pessoa ou casal, conhecidos como pais pretendidos. Quando as gestantes são pagas, isto é conhecido como gestação de substituição comercial. O objetivo do presente trabalho é rever os aspectos legais, éticos, sociais e culturais da gestação de substituição comercial, bem como o panorama atual em todo o mundo. Métodos Trata-se de uma revisão da literatura publicada no século XXI sobre a gestação de substituição comercial. Resultados Um total de 248 artigos foi incluído nesta revisão. A demanda por tratamentos com gestação de substituição por mulheres sem útero ou com distúrbios uterinos importantes, homens solteiros e casais masculinos está aumentando constantemente em todo o mundo. Este tratamento reprodutivo tem dilemas éticos importantes. Além disso, a legislação é amplamente adiada em todo o mundo e está em constante mudança. Portanto, os pacientes procuram cada vez mais por tratamentos no exterior, o que pode levar a importantes problemas legais entre países com leis diferentes. A gestação de substituição comercial é praticada em vários países, na maioria dos quais não há legislação específica. Alguns países tomaram medidas restritivas contra esta técnica por causa de relatos de exploração destas mulheres. Conclusão A gestação de substituição comercial é uma prática comum, apesar de importantes dilemas éticos e legais. Como consequência de diversas legislações nacionais, os pacientes frequentemente recorrem a programas de gestação de substituição comercial internacionais. Atualmente, não existe um contexto jurídico internacional padrão e esta prática permanece em grande parte não regulamentada. Received: 16 May 2022 Accepted: 25 August 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To describe the clinical results of patients admitted and managed as cases of placenta accreta spectrum (PAS) at a Central American public hospital and the influence of the prenatal diagnosis on the condition. Materials and Methods A retrospective analysis of PAS patients treated at Hospital Bertha Calderón Roque, in Managua, Nicaragua, between June 2017 and September 2021. The diagnostic criteria used were those of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French). The population was divided into patients with a prenatal ultrasonographic diagnosis of PAS (group 1) and those whose the diagnosis of PAS was established at the time of the caesarean section (group 2). Results: During the search, we found 103 cases with a histological and/or clinical diagnosis of PAS; groups 1 and 2 were composed of 51 and 52 patients respectively. Regarding the clinical results of both groups, the patients in group 1 presented a lower frequency of transfusions (56.9% versus 96.1% in group 2), use of a lower number of red blood cell units (RBCUs) among those undergoing transfusions (median: 1; interquartile range: [IQR]: 0–4 versus median: 3; [IQR]: 2–4] in group 2), and lower frequency of 4 or more RBCU transfusions (29.4% versus 46.1% in group 2). Group 1 also exhibited a non-significant trend toward a lower volume of blood loss (1,000 mL [IQR]: 750–2,000 mL versus 1,500 mL [IQR]: 1,200–1,800 mL in group 2), and lower requirement of pelvic packing (1.9% versus 7.7% in group 2). Conclusion Establishing a prenatal diagnosis of PAS is related to a lower frequency of transfusions. We observed a high frequency of prenatal diagnostic failures of PAS. It is a priority to improve prenatal detection of this disease.

Dear Editor, We thank Professor Chikazawa et al.[1] for their interest in our paper[2] and for highlighting the importance of simulation during training for the management of placenta accreta spectrum (PAS). There are multiple options to manage PAS and although the disease exhibits a wide variety of clinical presentations (spectrum), most groups choose a single therapeutic alternative and apply it to all their patients, making it difficult to respond when deviations from the original plan arise. Few publications propose a clear sequence of interventions applicable to all types of PAS. Our group uses the protocolized approach described by Palacios-Jaraquemada et al.[3] applicable to patients with suspected prenatal PAS, but also to those diagnosed intraoperatively, considering the nature (predominantly hypervascularization or presence of vesicouterine fibrosis) and the topography of the lesion (which uterine wall is affected, and which is the relationship of the lesion with the vesicouterine peritoneal fold).[3] [4] This protocol includes four steps ([Fig. 1]). First, the evaluation of the available resources and the clinical situation of the patient (to define whether or not to go ahead with the surgery). Doctor Chikazawa et al.[1] rightly point out that the process of training to manage PAS is a long one, and that obstetricians without such training are likely to be faced with the intraoperative finding of PAS. As useful as training in what to do, it is necessary to be very clear about what to avoid in the event of a PAS intraoperative finding, without the appropriate resources (human or technological), the greatest success of the obstetrician would be to avoid a high number of interventions when the clinical situation of the patient allows it. Second, intraoperative staging through 4 actions: opening of the parametrium (to evaluate the lateral uterine wall), digital evaluation of the retrovesical space (Pelosi maneuver), dissection of the retrovesical space by ligating the vesicouterine pedicles (to evaluate the anterior uterine wall), and exteriorization of the uterus to evaluate the posterior uterine wall. Third, the recommended treatment will be chosen (one step conservative surgery, total hysterectomy or modified subtotal hysterectomy) based on the topographic classification,[3] [4] and after answering the three following questions: Is it possible to separate the bladder from the uterus? Is there > 2 cm of healthy myometrium cephalic to the cervix and caudal to the PAS area? Does > 50% of the circumference of the uterus (in an axial section at the level of the PAS area) has healthy myometrium? ([Fig. 1]). Fourth and last, it is essential to have photographic and video recording elements of the surgical procedures to later on debrief, self-assess, and provide research activities that facilitate learning and continuous improvement of the performance of the group. A standardized approach facilitates the construction of a mental map that obstetricians can internalize or consult immediately, facilitating decision-making in the face of a planned or unexpected PAS case. Received: 15 September 2022 Accepted: 26 September 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy. Methods A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups. Results A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight. Conclusion This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.

Objective To determine how many patients underwent screening for diabetes mellitus (DM) in the puerperium after a diagnosis of gestational DM (GDM) and which factors were related to its performance. Methods The present is a prospective cohort study with 175 women with a diagnosis of GDM. Sociodemographic and clinico-obstetric data were collected through a questionnaire and a screening test for DM was requested six weeks postpartum. After ten weeks, the researchers contacted the patients by telephone with questions about the performance of the screening. The categorical variables were expressed as absolute and relative frequencies. The measure of association was the relative risk with a 95% confidence interval (95%CI), and values of p ≤ 0.05 were considered statistically significant and tested through logistic regression. Results The survey was completed by 159 patients, 32 (20.1%) of whom underwent puerperal screening. The mean age of the sample was of 30.7 years, and most patients were white (57.9%), married (56.6%), and had had 8 or more years of schooling (72.3%). About 22.6% of the patients used medications to treat GDM, 30.8% had other comorbidities, and 76.7% attended the postnatal appointment. Attendance at the postpartum appointment, the use of medication, and the presence of comorbidities showed an association with the performance of the oral glucose tolerance test in the puerperium. Conclusion The prevalence of screening for DM six weeks postpartum is low in women previously diagnosed with GDM. Patients who attended the postpartum consultation, used medications to treat GDM, and had comorbidities were the most adherent to the puerperal screening. We need strategies to increase the rate of performance of this exam.

Objective The use of granulocyte macrophage colony-stimulating factor (GM-CSF)-containing medium, which is a commercial medium that is used for cultivation of embryos in in vitro fertilization (IVF) treatments, has been suggested to increase the efficiency of this procedure in patients with previous multiple unsuccessful attempts. In this retrospective study, we analyzed GM-CSF-containing embryo culture media compared with traditional culture media in terms of development of embryos, pregnancy, and ongoing pregnancy success and live birth rates. Methods This is a prospective case control study conducted in a single center. A total of 131 unexplained infertility patients were included in the study. A cohort of 69 patients whose embryos were cultured in GM-CSF-containing medium and a control group of 62 age-matched patients whose embryos were cultured in conventional Sage One Step medium were included in the study. The major study outcomes were achievement of pregnancy and ongoing pregnancy rate at 12 weeks of gestation. Results The pregnancy and ongoing pregnancy rates of the patients whose embryos were cultured in GM-CSF-containing medium were 39.13% and 36.23%, respectively. These were higher than the rates of the control group, which were 30.65% and 29.03%, respectively, although this difference was not statistically significant. In addition, the 5^th-day embryo transfer percentage in the GM-CSF group was higher than in the control group (34.78% versus 27.4%). Conclusion The main findings of our study were that there was no difference between the GM-CSF-enhanced medium and the control group in terms of our major study outcomes. However, blastomere inequality rate and embryo fragmentation rates were lower in the GM-CSF group. All authors participated in the concept and design of the present study; analysis and interpretation of data; draft or revision of the manuscript, and they have approved the manuscript as submitted. All authors are responsible for the reported research. Received: 02 January 2022 Accepted: 09 September 2022 Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Adverse Events Related to COVID-19 Vaccines in Pregnant Women: Correspondence Spontaneous abortion is the most frequent adverse outcome in pregnancy, with a rate of 10% to 20% of all pregnancies. In Brazil, the rate of abortion before the COVID-19 pandemic was of 3.5%. In our study, we observed 24 miscarriages after 678,025 doses of COVID-19 vaccines had been administered in pregnant women in Brazil, which corresponds to an incidence of 3.5 cases per 100,000 doses.[1] Such incidence is lower than the postvaccination rate of abortion related to COVID-19 vaccines described by Trostle et al.[2] and much lower than the historical 3.5% expected rate in Brazil. Our study was observational and used passive surveillance data. Such studies cannot describe the exact rates of abortion in vaccinated pregnant women. Nonetheless, given the historical rates in Brazil, the expected number of abortions in 678,025 normal pregnancies would be 23,731, which averages out to 616 abortions per week of observation. Even if we consider reporting rates lower than 5%, our incidence of abortions would still be far below the expected.[3] Currently, the Brazilian Ministry of Health and the Pan American Health Organization (PAHO) are conducting a prospective active surveillance study with women who were vaccinated against COVID-19 during pregnancy in the 5 regions of the country. Such study will enable a more accurate description of the true rates of abortion and other adverse pregnancy outcomes in vaccinated women. It is already known that pregnant women have a higher risk of developing severe COVID-19 and an increased risk of having adverse maternal and neonatal outcomes after COVID-19. We believe that our data, in association with the previously-published literature, suggests that the benefits of vaccinating pregnant women against COVID-19 far outweighs the risk of the disease.[4] Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Objective To develop and validate a protocol for the use of the Dietary Guidelines for the Brazilian Population (DGBP) in the individual dietary advice for pregnant women assisted in primary healthcare (PHC). Methods Methodological study that involved the elaboration of a protocol in six steps: definition of the format, definition of the instrument to evaluate food consumption, systematization of evidence on food and nutrition needs of pregnant women, extraction of DGBP recommendations, development of messages of dietary guidelines and content, and face validity. The analyses of the validation steps were carried out by calculating the Content Validity Index (CVI) and thematic content analysis. Results As products of the steps, the protocol structure was defined and the dietary advice for pregnant women were elaborated, considering physiological changes, food consumption, nutritional and health needs, and socioeconomic conditions of this population. The protocol was well evaluated by experts and health professionals in terms of clarity, relevance (CVI > 0.8), and applicability. In addition, the participants made some suggestions to improve the clarity of the messages and to expand the applicability of the instrument with Brazilian pregnant women. Conclusion The instrument developed fills a gap in clinical protocols on dietary advice for pregnant women focused on promoting a healthy diet, contributing to a healthy pregnancy. In addition, it demonstrates potential to contribute to the qualification of PHC professionals and to the implementation of the DGBP recommendations.

Objective Nipple-sparing mastectomy (NSM) has been traditionally used in selected cases with tumor-to-nipple distance > 2 cm and negative frozen section of the base of the nipple. Recommending NSM in unselected populations remains controversial. The present study evaluated the oncological outcomes of patients submitted to NSM in an unselected population seen at a single center. Methods This retrospective cohort study included unselected patients with invasive carcinoma or ductal carcinoma in situ (DCIS) who underwent NSM in 2010 to 2020. The endpoints were locoregional recurrence, disease-free survival (DFS), and overall survival (OS), irrespective of tumor size or tumor-to-nipple distance. Results Seventy-six patients (mean age 46.1 years) (58 invasive carcinomas/18 DCIS) were included. The most invasive carcinomas were hormone-positive (60%) (HER2 overexpression: 24%; triple-negative: 16%), while 39% of DCIS were high-grade. Invasive carcinomas were T2 in 66% of cases, with axillary metastases in 38%. Surgical margins were all negative. All patients with invasive carcinoma received systemic treatment and 38% underwent radiotherapy. After a mean of 34.8 months, 3 patients with invasive carcinoma (5.1%) and 1 with DCIS (5.5%) had local recurrence. Two patients had distant metastasis and died during follow-up. The 5-year OS and DFS rates for invasive carcinoma were 98% and 83%, respectively. Conclusion In unselected cases, the 5-year oncological outcomes following NSM were found to be acceptable and comparable to previous reports. Further studies are required.

Ultrasonography is an instrument that is present in the maternal-fetal assessment throughout pregnancy and with widely documented benefits, but its use in intrapartum is becoming increasingly relevant. From the assessment of labor progression to the assessment of placental disorders, ultrasound can be used to correlate with physiological findings and physical examination, as its benefit in the delivery room cannot yet be proven. There are still few professionals with adequate training for its use in the delivery room and for the correct interpretation of data. Thus, this article aims to present a review of the entire applicability of ultrasound in the delivery room, considering the main stages of labor. There is still limited research in evidence-based medicine of its various possible uses in intrapartum, but it is expected that further studies can bring improvements in the quality of maternal and neonatal health during labor.

In the month of October, the World Day against Osteoporosis was celebrated and the date is dedicated to the global awareness of its prevention, diagnosis and treatment. This disease affects about 200 million people worldwide, causing more than 8.9 million fractures annually.[1] [2] Globally, it affects 21.2% of women over 50 years of age.[3] Fractures caused by osteoporosis have great importance not only because of their high prevalence, but also because of their serious physical, psychosocial and financial consequences that affect both individuals and their families, the community and health systems. Considering these demographic aspects of the disease, the Brazilian Federation of Gynecology and Obstetrics Associations – FEBRASO - joined other organizations and medical societies in the campaign, since climacteric women are among the population most at risk for osteoporosis, who nowadays correspond to a large percentage of patients in gynecology offices. According to surveys by DataFolha, one of the main institutes of public opinion in Brazil, eight in every ten women consider the specialty of Gynecology and Obstetrics as the most important for women's health in Brazil.[4] For brazilian women , Gynecologist-Obstetricians are considered as reference physicians, whether for treating problems of the specialty, as well as for counseling and guidance when they need healthcare in another medical specialty.[4] Thus, the gynecologist's office becomes one of the main entry points into the health system for women, and this professional should become a true sentinel in the screening for osteoporosis, seeking to identify women at risk for fractures. Therefore, gynecologists must be prepared for this task and also Also to refer the patient when the osteoporosis etiology requires joint care with another medical specialty since this disease has multiple origins and patients often require multidisciplinary follow-up. Thus the Competence Matrix for Medical Residency Programs in Gynecology and Obstetrics stablished by FEBRASGO emphasize the attention to climacteric women's health.[5] In addition, Febrasgo created the National Specialized Commission on Osteoporosis, which has been developing an excellent work, aiming to reinforce the fundamentals to approach patients at risk for osteoporosis. . With the active participation of members of that Commission, the Brazilian Osteoporosis Manual was recently launched, conceived as a practical guidelines for health professionalss.[6] Once the osteoporosis have been identified, it is essential that the physician offer to the patient all the information about the disease in order that she must be awared about the risks of suffering fracture. Thousands of women with this silent disease are unaware of these risks. Currently there are international consensus regards the necessity of the patients to change her lifestyle, adequate diet, use of calcium and vitamin D, physical exercise, avoiding alcoholic beverages, among others, in addition to supplementing with medication when necessary. Several options of pharmacological treatment are available on the market, such as Hormone Replacement Therapy (HT), Bisphosphonates (BP), Selective Estrogen Receptor Modulator (SERMs), Denosumab, Teriparatide and others still being studied. All options have advantages and disadvantages and the choice will depend on the professional's experience in dealing with each medication, considering its possible side effects and/or complications of its use. Since the disease has multiple triggering factors and patients are treated by different medical specialties, drug therapy has varied according to treatment protocols established by different specialty societies. It is known that one of the main trigger for the development of osteoporosis in women is estrogen deficiency consequent to physiological or induced ovarian failure, which determines an increase in bone resorption that is not compensated by an equivalent increase in formation.[7] The medical literature has consistently and significantly shown that HT (encompassing both estrogenic therapy and estrogen-progestin therapy ) is indicated for climacteric women when they presented with vasomotor symptoms and genitourinary syndrome of menopause. Besides that, TH may be considered to be used to prevent bone loss and fragility fractures.[8] [9] [10] Estrogens have a positive effect on reducing the risk of fractures of the hip, vertebrae and other related fractures in postmenopausal women. It is the only therapy available with proven randomized clinical trials presenting effectiveness in reducing fractures, even in groups of women who do not have an identified risk for fractures or who have a T-score in the normal or osteopenic range in bone mineral densitometry (BMD).[11] Considering its well-known contraindications,[10] [12] the HT in climacteric can be started in women at risk of fractures or osteoporosis before the age of 60 or within the first ten years after menopause (window of opportunity). There is an international consensus supported by influential Specialty Societies that indicate its use, evidently establishing individualized safety criteria for each patient.[9] HT would be the best choice for climacteric women in that period, because in addition to the undeniable benefits on bone mass, , patients have the opportunity to the additional benefits offered by HT, such as the prevention or abolition of hot flashes, , protection against genitourinary syndrome of menopause and its consequences on sexual health, positive effects on collagen and skin and significantly improving in sleep and quality of life.[10] Since HT is a routine prescription for gynecologists, it should obviously be the first choice for these patients, considering the extra benefits mentioned above. However, contrary to what is expected, an increasing use of BP has been observed as the first choice among gynecologists rather than HT, even for those climacteric...

Objective Cervical pregnancy is challenging for the medical community, as it is potentially fatal. The treatment can be medical or surgical; however, there are no protocols that establish the best option for each case. The objective of the present study was to describe the cases of cervical pregnancy admitted to a tertiary university hospital over a period of 18 years. Methods A retrospective study based on a review of the medical records of all cervical pregnancies admitted to the Women's Hospital at Universidade Estadual de Campinas, Southeastern Brazil, from 2000 to 2018. Results We identified 13 cases of cervical pregnancy out of a total of 673 ectopic pregnancies; only 1 case was initially treated with surgery because of hemodynamic instability. Of the 12 cases treated conservatively, 7 were treated with single-dose intramuscular methotrexate, 1, with intravenous and intramuscular methotrexate, 1, with intravenous methotrexate, 1, with 2 doses of intramuscular methotrexate, and 2, with intra-amniotic methotrexate. Of these cases, one had a therapeutic failure that required a hysterectomy. Two women received blood transfusions. Four women required cervical tamponade with a Foley catheter balloon for hemostasis. There was no fatal outcome. Conclusion Cervical pregnancy is a rare and challenging condition from diagnosis to treatment. Conservative treatment was the primary method of therapy used, with satisfactory results. In cases of increased bleeding, cervical curettage was the initial treatment, and it was associated with the use of a cervical balloon for hemostasis.

Authors' reply Dear Editor, We would like to share ideas on the publication “Adverse Events Related to COVID-19 Vaccines Reported in Pregnant Women in Brazil.”[1] According to Kobayashi et al.,[1] ten deaths were identified, one of which was thought to be causally related to the vaccine, and the other nine maternal deaths had causality C, that is, no causal relationship with the vaccine, and the majority were due to complications inherent in pregnancy, such as pregnancy-specific hypertensive disorder (PSHD) in four cases, and COVID-19 in three.[1] The problem of the efficacy and safety of the COVID-19 vaccine for pregnant women is intriguing, and evidence from real-world situations are needed.[2] Aside from death, there are further concerns about the safety of the COVID-19 vaccine for pregnant women, including the induction of abortion.[3] We are all concerned that, despite its benefits, the COVID-19 vaccine may be harmful. It is difficult to determine the exact source of the clinical issue in this case due to a lack of information on the health and immunological status of vaccination recipients prior to inoculation. People may reject vaccines and lose faith in them if they are given contradicting information. A clinical comorbidity may be at the basis of the problem.[4] [5] The assessment of potential detrimental outcomes is now too early due to incomplete documentation of a person's health or immune condition prior to immunization. Article published online: 29 December 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Studies have consistently shown a significant increase in the risk of congenital heart defects in the offspring of diabetic mothers compared with those of nondiabetic pregnancies. Evidence points that all types of pregestational diabetes have the capacity of generating cardiac malformations in a more accentuated manner than in gestational diabetes, and there seems to be an increased risk for all congenital heart defects phenotypes in the presence of maternal diabetes. Currently, the application of some therapies is under study in an attempt to reduce the risks inherent to diabetic pregnancies; however, it has not yet been possible to fully prove their effectiveness. The present review aims to better understand the mechanisms that govern the association between pregestational diabetes and congenital heart defects and how maternal diabetes interferes with fetal cardiac development, as there is still a long way to go in the investigation of this complex process.

Objective To evaluate the efficacy of the hormonal and nonhormonal approaches to symptoms of sexual dysfunction and vaginal atrophy in postmenopausal women. Data Sources We conducted a search on the PubMed, Embase, Scopus, Web of Science, SciELO, the Cochrane Central Register of Controlled Trials (CENTRAL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, as well as on clinical trial databases. We analyzed studies published between 1996 and May 30, 2020. No language restrictions were applied. Selection of Studies We selected randomized clinical trials that evaluated the treatment of sexual dysfunction in postmenopausal women. Data Collection Three authors (ACAS, APFC, and JL) reviewed each article based on its title and Relevant data were subsequently taken from the full-text article. Any discrepancies during the review were resolved by consensus between all the listed authors. Data Synthesis A total of 55 studies were included in the systematic review. The approaches tested to treat sexual dysfunction were as follows: lubricants and moisturizers (18 studies); phytoestrogens (14 studies); dehydroepiandrosterone (DHEA; 8 studies); ospemifene (5 studies); vaginal testosterone (4 studies); pelvic floor muscle exercises (2 studies); oxytocin (2 studies); vaginal CO₂ laser (2 studies); lidocaine (1 study); and vitamin E vaginal suppository (1 study). Conclusion We identified literature that lacks coherence in terms of the proposed treatments and selected outcome measures. Despite the great diversity in treatment modalities and outcome measures, the present systematic review can shed light on potential targets for the treatment, which is deemed necessary for sexual dysfunction, assuming that most randomized trials were evaluated with a low risk of bias according to the Cochrane Collaboration risk of bias tool. The present review is registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100488). Objetivo Avaliar a eficácia das abordagens hormonais e não hormonais para os sintomas de disfunção sexual e atrofia vaginal em mulheres na pós-menopausa. Fontes de Dados Pesquisamos as bases de dados PubMed, Embase, Scopus, Web of Science, SciELO, Cochrane Central Register of Controlled Trials (CENTRAL), e Cumulative Index to Nursing and Allied Health Literature (CINAHL), assim como bancos de dados de ensaios clínicos. Foram analisados estudos publicados entre 1996 e 30 de maio de 2020. Nenhuma restrição de idioma foi aplicada. Seleção dos Estudos Foram selecionados ensaios clínicos randomizados que avaliavam o tratamento das disfunções sexuais em mulheres na pós-menopausa. Coleta de Dados Três autores (ACAS, APFC e JL), revisaram cada artigo com base em seu título e resumo. Os dados relevantes foram posteriormente retirados do texto completo do artigo. Quaisquer discrepâncias durante a revisão foram resolvidas por consenso entre todos os autores listados. Síntese dos Dados Ao todo, 55 estudos foram incluídos na revisão sistemática. As abordagens testadas para tratar a disfunção sexual foram: lubrificantes e hidratantes (18 estudos); fitoestrogênios (14 estudos); deidroepiandrosterona (DHEA; 8 estudos); ospemifeno (5 estudos); testosterona vaginal (4 estudos); exercícios para os músculos do assoalho pélvico (2 estudos); oxitocina (2 estudos); laser de CO₂ vaginal (2 estudos); lidocaína (1 estudo), e vitamina E vaginal (1 estudo). Conclusão Identificou-se falta de coerência na literatura quanto aos tratamentos propostos e medidas de resultados selecionadas. Apesar da grande diversidade de modalidades de tratamento e medidas de resultados, esta revisão sistemática pode lançar luz sobre alvos potenciais para o tratamento, que é considerado necessário para a disfunção sexual, assumindo que a maioria dos estudos randomizados foi avaliada com baixo risco de viés de acordo com a ferramenta de avaliação de risco de viés de Cochrane Collaboration. Esta revisão tem cadastro no International Prospective Register of Systematic Reviews (PROSPERO; CRD42018100488). Received: 17 August 2020 Accepted: 06 October 2020 Article published online: 29 November 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To evaluate the iodine sufficiency of pregnant women assisted in a University Hospital of Minas Gerais, and to correlate the urinary concentrations of maternal iodine with the fetal thyroid hormone levels at birth. Methods Urinary iodine concentrations from 30 pregnant women with a singleton pregnancy and gestational age lower than 20 weeks were analyzed. Occasional samples of the mothers' urine were collected for the urinary iodine concentration dosage, and these were correlated with the newborns' thyroid-stimulating hormone (TSH) levels. Results The median iodine urinary concentration of this study's pregnant women population was 216.73 mcg/l, which is proper for the group, following the World Health Organization (WHO). No cases of neonatal hypothyroidism were reported in the study, which corroborates the iodine sufficiency in this population sample. Conclusion This study shows that despite the increased demand for iodine from pregnant women and the Brazilian Health Regulatory Agency (ANVISA) recommendation of 2013 for reduction of salt iodization levels, the population of pregnant women attended in the prenatal ambulatory of normal risk from the Federal University of Minas Gerais is considered sufficient in iodine. As a higher sample is necessary for the confirmation of these findings, it is too early to recommend the universal supplementation of iodine for Brazilian pregnant women, and more studies must be carried out, considering that iodine supplementation for pregnant women in an area of iodine sufficiency is associated to the risks of the fetus's excessive exposure to iodine.

Objective To assess the association between two colposcopic indices, the Swede score and the 2011 International Federation of Cervical Pathology and Colposcopy (IFCPC) Nomenclature as well as to determine the efficacy of the Swede score with cutoffs of 7 and 8. Methods In the present cross-sectional pilot study, 34 women who had at least 1 colposcopy-directed biopsy due to abnormal cytology were enrolled. The colposcopic findings were scored by both the Swede score and the 2011 IFCPC Nomenclature and were compared with each other. The Kappa coefficient and the McNemar test were used. Accuracy, sensitivity, specificity, and positive and negative predictive values (NPV and PPV, respectively) were calculated, as well as the effectiveness with cutoffs of 7 and 8 in identifying cervical intraepithelial neoplasm (CIN) 2+ when using the Swede score. Results The correlation between the 2 colposcopic indices was 79.41%. The Kappa coefficient and the McNemar p-value were 0.55 and 0.37, respectively. The IFCPC Nomenclature had sensitivity, specificity, accuracy, PPV, and NPV of 85.71, 55.00, 67.64, 57.14, and 84.61%, respectively. The Swede score had sensitivity, specificity, accuracy, PPV, and NPV of 100, 63.15, 79.41, 68.18, and 100%, respectively. A Swede score cutoff of 7 for CIN 2+ detection had a specificity of 94.73%, while with a cutoff of 8 it increased to 100%. The sensitivity for both values was 60%. The PPV and NPV for cutoffs of 7 and 8 were 90 and 75 and 100 and 76%, respectively. Conclusion Although both colposcopic indices have good reproducibility, the Swede score showed greater accuracy, sensitivity, and specificity in identifying CIN 2 + , especially when using a cutoff of 8.

Objective Different drugs are used to treat mastalgia, such as danazol and bromocriptine, and both are associated with side effects, due to which most of women and healthcare providers are interested in herbal medicines. Therefore we aim to study the effectiveness of phytoestrogens on the severity of cyclic mastalgia. Methods To carry out the present study, English electronic resources such as the Cochrane Library, ISI Web of Science, Scopus, and PubMed were used systematically and with no time limitation up to February 10, 2020. Results In total, 20 studies were included in the present meta-analysis. The results of the meta-analysis showed that herbal medicines versus the control group (standard mean difference [SMD] = - 0.585; 95% confidence interval [CI]: - 0.728–- 0.44; heterogeneity; p = 0.02; I2 = 42%), herbal medicines versus the B group (SMD = - 0.59; 95%CI: - 0.75–- 0.44; heterogeneity; p = 0.03; I2 = 42%), and its subgroups, such as phytoestrogen (SMD = - 0.691; 95%CI: - 0.82–- 0.55; heterogeneity; p = 0.669; I2 = 0%), Vitex-agnus-castus (SMD = - 0.642; 95%CI: - 0.84–- 0.44; p < 0.001; p = 203; I2 = 32%), flaxseed (SMD = - 0.63; 95%CI: - 0.901–- 0.367; p = 0.871; I2 = 0%), and evening primrose (SMD= - 0.485; 95%CI:- 0.84–- 0.12; p = 0.008; heterogeneity; p = 0.06; I2 = 56%] may have effective and helpful effects on improving cyclic breast mastalgia. Also, chamomile, isoflavone, cinnamon, and nigella sativa significantly reduced mastalgia symptoms. Conclusion Herbal medicines and their subgroups may have effective and helpful effects on improving cyclic breast mastalgia. The findings of our meta-analysis must be done cautiously because low methodological quality in some evaluated studies of this systematic review.

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.

The National Commission Specialized in High Risk Pregnancy of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and the Thyroid Department of the Brazilian Society of Endocrinology and Metabology (SBEM) endorse this document. The production of content is based on scientific evidence on the proposed theme and the results presented contribute to clinical practice. Article published online: 29 November 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To determine whether a rescue strategy using dydrogesterone (DYD) could improve the outcomes of frozen embryo transfer cycles (FET) with low progesterone (P4) levels on the day of a blastocyst transfer. Methods Retrospective cohort study including FET cycles performed between July 2019 and October 2020 following an artificial endometrial preparation cycle using estradiol valerate and micronized vaginal P4 (400 mg twice daily). Whenever the serum P4 value was below 10 ng/mL on the morning of the planned transfer, DYD 10 mg three times a day was added as supplementation. The primary endpoint was ongoing pregnancy beyond 10 weeks. The sample was subdivided into two groups according to serum P4 on the day of FET: low (< 10 ng/mL, with DYD supplementation) or normal (above 10 ng/mL). We performed linear or logistic generalized estimating equations (GEE), as appropriate. Results We analyzed 304 FET cycles from 241 couples, 11.8% (n = 36) of which had serum P4 below 10 ng/mL on the FET day. Baseline clinical data of patients was comparable between the study groups.Overall, 191 cycles (62.8%) had a biochemical pregnancy, of which 131 (44,1%) were ongoing pregnancies, with a 29,8% miscarriage rate. We found no statistically significant differences in the hCG positive (63 vs 64%) or ongoing pregnancy rates (50 vs 43,3%) between those FETs with low or normal serum P4 values, even after multivariable logistic regression modelling. Conclusion Our results indicate that DYD 10 mg three times a day administered in women who perform FET with P4 serum levels < 10 ng/mL, allows this group to have pregnancy rates beyond 12 weeks at least as good as those with serum levels above 10 ng/mL.

Dear Editor, We enthusiastically read the analysis conducted in the study Adequacy of Prenatal Care During The COVID-19 Pandemic: An Observational Study with Postpartum Women,[1] published in volume 44 issue #4 of the Brazilian Journal of Gynecology and Obstetrics in 2022, and would like to bring some considerations about the topic. According to the World Health Organization (WHO), investing in prenatal care is essential to improve one of the most important indicators of quality of life for the world population, which is maternal mortality, in which Brazil is below the rate stipulated as ideal.[2] The state of Santa Catarina and the South region, according to national data, stand out for the lowest rates of maternal mortality, better prenatal care coverage, and quality of prenatal care.[3] [4] However, the few current studies analyzing the quality of prenatal care in this region differ from the data made available by the Ministry of Health (MH).[1] [5] Thus, it is pertinent to emphasize that this study has great value by making a careful analysis of this assistance. As the authors point out in the limitations of the study, the diversity of criteria used to evaluate the quality of prenatal care makes a more complete and comparative analysis of the data difficult.[1] The Brazilian government uses criteria with few variables for prenatal care adequacy, using the Kotelchuck index,[6] which takes into account only the date of prenatal care initiation and the number of appointments. Thus, the data found in national studies differ from the MH database. Between the years 2012 and 2013, Tomasi et al.[7] found in a national survey with 50,791 participants only 21% adequacy to prenatal care, while for the MH, in the year 2014, the national adequacy was 63%. Therefore, the development of robust studies that confront the findings and justify such divergence becomes pertinent. Most studies analyze how well the current MH guidelines[8] are being met, while others analyze national and even international indexes. However, there are no uniform and well-accepted criteria for the classification of the adequacy of prenatal care; besides, there is no uniformity in the way data is collected, resulting in values with large variations and making it difficult to compare the populations studied.[9] As an example, we can cite the Northeast region of Brazil, which, according to the WHO, has a prenatal care quality index lower than the national average;[10] however, in a study conducted in Paraiba in 2018, a good quality was verified with > 80% of prenatal visits starting at the ideal time and with an adequate number of appointments, and having > 90% of the necessary exams performed.[11] According to the study by Martin et al.,[1] in the year 2020, amid the COVID-19 pandemic, 35.8% of prenatal care were considered adequate, 46.8% intermediate, and 17.4% inadequate. In the previous year, according to the MH, 79.3% of prenatal care for Southern Brazil were considered adequate. This important difference is probably not only related to the pandemic, since other studies out of the pandemic period have even lower values of adequacy.[5] [12] Weaknesses in assistance were found in a study from the most populous city of Santa Catarina: only 17% of the patients received proper guidance during pregnancy and less than half of the patients underwent 3^rd trimester exams (42.5%).[5] Regarding the study in question, the authors claim to use not very strict parameters to assess the quality of prenatal care, such as the week of the beginning of prenatal care being appropriate under 16 weeks; however, since 2012, the MH recommends starting before 12 weeks.[8] The procedures recommended as adequate were the performance of three tests: syphilis, HIV, and urinary tract infection in the 3^rd trimester. Additionally, since 2012, the following are recommended as essential for a quality prenatal care: immunization for hepatitis B and Diphtheria and tetanus vaccine (DT), and performance of. obstetric clinical procedures such as weight, blood pressure, edema, body mass index, uterine height, fetal heartbeat, fetal movements, fetal presentation in the appointments conducted, and laboratory tests for each trimester. In addition to the prescription of ferrous sulfate and folic acid supplements and guidance related to the prenatal period, delivery, puerperium, breastfeeding, newborn care, healthy habits, and emotional and body modifications.[8] It is assumed, therefore, that the percentage of adequacy in this study was overestimated by considering only the minimum necessary, and the impact of the pandemic on prenatal care must have been even greater than estimated. As long as studies are conducted in a nonuniform manner, using different assessment approaches and not meeting the recommendations of the MH,[8] we will not know exactly how the healthcare of pregnant women is at the regional and national levels. Thus, a complete analysis would require the use of the different criteria available in order to allow the applicability of the results in the development of assertive improvement policies. Received: 24 June 2022 Accepted: 29 June 2022 Article published online: 29 November 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Fear encompasses concerns on a spectrum ranging from mild fear to phobia.[1] When it comes to fear related to childbirth, there is no consensus on its exact definition. However, there is no doubt about its importance in obstetric care.[2] [3] [4] When fear of childbirth is intense, it can harm the woman's health,[5] [6] becoming a disabling factor that interferes with the daily routine, such as occupational and domestic activities and social life.[7] There are disagreements regarding the prevalence of fear of childbirth (FOC) due to the lack of consensus on its definition, as well as the differences in the diagnostic methods adopted by the studies.[7] [8] [9] In general, it is known that some degree of concern and fear can be presented by up to 80% of pregnant women.[10] [11] In Brazil, this topic is rarely discussed among health professionals, and the assessment of its real prevalence remains unknown. Some protective factors can lead to lower incidences of FOC, such as relationship stability and duration. In turn, there are risk factors that can increase its incidence, such as lack of social support; unplanned pregnancy; infertility; previous negative experiences; anxiety, depression, and other psychological disorders.[12] Younger women tend to be more afraid of childbirth than older women. The woman's nationality also seems to influence the occurrence of FOC.[13] Among the obstetric aspects, nulliparity, advanced gestational age and a history of previous cesarean section stand out as risk factors for FOC.[10] [14] The preference for cesarean section is expressed by 27% of women who use the public health system and by 44% of those who access private health services in Brazil. In addition to social, economic, and cultural aspects, fear of labor pain and childbirth itself seem to be factors that could influence the mother's preference for cesarean section.[15] [16] [17] Besides the maternal request for cesarean section, the increase in other adverse obstetric outcomes such as preterm birth, prolonged labor, postpartum depression, and post-traumatic stress have already been related to the fear of childbirth. It is extremely important to establish treatment plans for identified cases of FOC to minimize its negative impacts on obstetric outcomes. Accessible and timely interventions, which can contribute to the reduction of FOC, include educational and reassuring measures such as the construction of a birth plan; discussion groups with pregnant women and health professionals; access to educational materials on delivery mechanisms and obstetric care; establishment of a support network; empathic follow-up; psychological support. In more severe cases, it is essential to refer the pregnant woman to professionals specialized in mental health for better monitoring and control of symptoms. There are still little data in the literature on the prevalence, predictive and protective factors concerning fear of childbirth according to each population, considering the obstetric history and social, economic, and cultural aspects. A research group linked to the Ribeirão Preto Medical School of the University of São Paulo is evaluating this issue, to characterize the context of FOC in the Brazilian population and analyze the effectiveness of possible interventions to reduce the impact of this condition. Furthermore, it is intended to promote the discussion on the need for public policies aimed at identifying the fear of childbirth during prenatal care, implementing strategies to improve the education of the population regarding the physiology of childbirth and obstetric care (including information on the mode of delivery and its risks/benefits, delivery plan, labor pain management, evidence-based interventions that can occur during labor and delivery) and, consequently, expand access to these resources. FOC exists, it is a real problem, but it remains masked by the knowledge gaps on the subject. Thus, it is essential to develop studies, establish guidelines, and train health professionals on this important issue. There is an urgent need to implement diagnostic and management measures for these cases in clinical practice. It is time to talk about it! Article published online: 29 November 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective To analyze the cases of all women who attend to a service of legal termination of pregnancy in cases of sexual violence in a public reference hospital and to identify the factors related to its execution. Methods Cross-sectional observational study with information from medical records from January 2014 to December 2020. A total of 178 cases were included, with an evaluation of the data referring to the women who attended due to sexual violence, characteristics of sexual violence, hospital care, techniques used, and complications. The analysis was presented in relative and absolute frequencies, medians, means, and standard deviation. Factors related to the completion of the procedure were assessed using binary logistic regression. Results Termination of pregnancy was performed in 83.2% of the cases; in 75.7% of the cases, the technique used was the association of transvaginal misoprostol and intrauterine manual aspiration. There were no deaths, and the rate of complications was 1.4%. Gestational age at the time the patient's sought assistance was the determining factor for the protocol not being completed. Pregnancies up to 12 weeks were associated with a lower chance of the interruption not occurring (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.12–0.88), while cases with gestational age > 20 weeks were associated with a greater chance of the interruption not happening (OR: 29.93; 95%CI: 3.91–271.50). Conclusion The service studied was effective, with gestational age being the significant factor for resolution.

Objective To explore the main sexuality complaints of gynecologic cancer survivors after treatment and to identify the care strategies provided. Data Source Searches were conducted in six electronic databases: Scopus, Web of Science, LILACS, MEDLINE, PsychINFO, and EMBASE. Study Selection Articles published between 2010 and 2020 were selected and the following descriptors were used in the English language: female genital neoplasms and gynaecological cancer. The methodological quality of the studies used the Mixed Methods Appraisal Tool (MMAT). Data Collection The primary data extracted were: names of the authors, year of publication, country of origin, objective and type of study, data collection instrument, sample size and age range, types of cancer, and symptoms affected with the strategies adopted. Data Summary A total of 34 out of 2,536 screened articles were included. The main strategies found for patient care were patient-clinician communication, practices for sexuality care, individualized care plan, multiprofessional team support, and development of rehabilitation programs. For sexuality care, the most common practices are pelvic physiotherapy sessions and the use of vaginal gels and moisturizers. Conclusion The main complaints identified in the scientific literature were low libido and lack of interest in sexual activity, vaginal dryness, pain during sexual intercourse, and stenosis. Different care strategies may be adopted, such as follow-up with a multidisciplinary health team and sexual health rehabilitation programs, which could minimize these symptoms and ensure the quality of life of patients.

Objective The aim of this study was to evaluate the use of vaginal molds, made with three-dimensional (3D) printing, for conservative treatment through vaginal dilation in patients with vaginal agenesis (VA). Methods A total of 16 patients with a diagnosis of VA (Mayer-Rokitansky-Küster-Hauser syndrome, total androgen insensitivity syndrome, and cervicovaginal agenesis) from the Federal University of São Paulo were selected. Device production was performed in a 3D printer, and the polymeric filament of the lactic polyacid (PLA) was used as raw material. A personalized treatment was proposed and developed for each patient. Results There were 14 patients who reached a final vaginal length of 6 cm or more. The initial total vaginal length (TVL) mean (SD) was 1.81(1.05) and the final TVL mean (SD) was 6.37 (0.94); the difference, analyzed as 95% confidence interval (95% CI) was 4.56 (5.27–3.84) and the effect size (95% CI) was 4.58 (2.88–6.28). Conclusion The 3D printing molds for vaginal dilation were successful in 87.5% of the patients. They did not present any major adverse effects and offered an economical, accessible, and reproducible strategy for the treatment of VA.

Objective The purpose was to assess the rates of postoperative complications and the need of temporary stoma of laparoscopic surgical treatment for bowel endometriosis in a referral center. Methods The surgical indication, type of operation, operative time, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, postoperative complications were evaluated. Results One-hundred and fifty patients were included. The average duration of surgery was significantly longer for segmental resection (151 minutes) than for disc excision (111.5 minutes, p < 0.001) and shaving (96.8 minutes, p < 0.001). Patients with segmental resection had longer postoperative lengths of hospital stay (1.87 days) compared with patients with disc excision (1.43 days, p < 0.001) and shaving (1.03 days, p < 0.001). A temporary stoma was performed in 2.7% of patients. Grade II and III postoperative complications occurred in 6.7% and 4.7% patients, respectively. Conclusion Laparoscopic intestinal resection has an acceptable postoperative complication rate and a low need for a temporary stoma.

Objective Placenta accreta spectrum (PAS) is a cause of massive obstetric hemorrhage and maternal mortality. The application of family-centered delivery techniques (FCDTs) during surgery to treat this disease is infrequent. We evaluate the implementation of FCDTs during PAS surgeries. Methods This was a prospective, descriptive study that included PAS patients undergoing surgical management over a 12-month period. The patients were divided according to whether FCDTs were applied (group 1) or not (group 2), and the clinical outcomes were measured. In addition, hospital anesthesiologists were surveyed to evaluate their opinions regarding the implementation of FCDTs during the surgical management of PAS. Results Thirteen patients with PAS were included. The implementation of FCDTs during birth was possible in 53.8% of the patients. The presence of a companion during surgery and skin-to-skin contact did not hinder interdisciplinary management in any case. Conclusion Implementation of FCDTs during PAS care is possible in selected patients at centers with experience in managing this disease.

Regulations for the vaccination of pregnant women in Brazil occurred in March 2021. Despite the absence of robust data in the literature on the coronavirus disease 2019 (COVID-19) vaccinations in pregnant women, it is understood that the benefit-risk ratio tends to be favorable when considering the pandemic and the high burden of the disease. However, it is still important to monitor for Events Supposedly Attributable to Vaccination or Immunization (ESAVI) and to draw safety profiles of the different platforms used in pregnant and postpartum women. The present study aims to describe the main characteristics of ESAVIs related to COVID-19 vaccines occurring in pregnant women in the first months of the vaccination campaign in Brazil. During the evaluation period, 1,674 notifications of ESAVIs in pregnant women were recorded, and 582 notifications were included for the analysis. Of the 582 ESAVIs identified, 481 (82%) were classified as non-serious adverse events and 101 (17%) as serious adverse events. Ten deaths were identified, including one death which was considered to be causally related to the vaccine. The other nine maternal deaths had causality C, that is, without causal relationship with the vaccine, and most were due to complications inherent to pregnancy, such as pregnancy-specific hypertensive disorder (PSHD) in 4 cases and 3 due to COVID-19. Despite some limitations in our study, we believe it brings new insights into COVID-19 vaccines in this group and will add to the available evidence.

Objective The aim of this study was to systematically review literature on the use of iron supplements (not including iron derived from diet), increased levels of hemoglobin and/or ferritin, and the risk of developing gestational diabetes mellitus (GDM). Data source The following databases were searched, from the study's inception to April 2021: PUBMED, Cochrane, Web of Science, Scopus, Embase, Cinahl and Lilacs. Selection of studies A total of 6,956 titles and abstracts were reviewed, 9 of which met the final inclusion criteria, with 7,560 women in total. Data collection Data extraction was performed by two independent reviewers and disagreements were resolved by a third researcher. Data synthesis Methodological quality in controlled trials were assessed according to the Cochrane Collaboration tools (ROB-2 and ROBINS-1) and for the observational studies, the National Institutes of Health's (NIH) quality assessment tool was used. Among the 5 observational studies, women with a higher hemoglobin or ferritin level were more likely to develop GDM when compared with those with lower levels of these parameters. Among the 3 randomized clinical trials, none found a significant difference in the incidence of GDM among women in the intervention and control groups. However, we identified many risks of bias and great methodological differences among them. Conclusion Based on the studies included in this review, and due to the important methodological problems pointed out, more studies of good methodological quality are needed to better establish the association between iron supplementation and GDM.

Objective The immediate referral of patients with risk factors for placenta accreta spectrum (PAS) to specialized centers is recommended, thus favoring an early diagnosis and an interdisciplinary management. However, diagnostic errors are frequent, even in referral centers (RCs). We sought to evaluate the performance of the prenatal diagnosis for PAS in a Latin American hospital. Methods A retrospective descriptive study including patients referred due to the suspicion of PAS was conducted. Data from the prenatal imaging studies were compared with the final diagnoses (intraoperative and/or histological). Results A total of 162 patients were included in the present study. The median gestational age at the time of the first PAS suspicious ultrasound was 29 weeks, but patients arrived at the PAS RC at 34 weeks. The frequency of false-positive results at referring hospitals was 68.5%. Sixty-nine patients underwent surgery based on the suspicion of PAS at 35 weeks, and there was a 28.9% false-positive rate at the RC. In 93 patients, the diagnosis of PAS was ruled out at the RC, with a 2.1% false-negative frequency. Conclusion The prenatal diagnosis of PAS is better at the RC. However, even in these centers, false-positive results are common; therefore, the intraoperative confirmation of the diagnosis of PAS is essential.

Objective To use the Robson Ten Group Classification (RTGC) to analyze cesarean section (CS) rates in a Honduran maternity hospital, with focus in groups that consider induction of labor. Methods Cross-sectional study. Women admitted for childbirth (August 2017 to October 2018) were classified according to the RTGC. The CS rate for each group and the contribution to the overall CS rate was calculated, with further analyses of the induction of labor among term primiparous (group 2a), term multiparous (group 4a), and cases with one previous CS (group 5.1). Results A total of 4,356 women were considered, with an overall CS rate of 26.1%. Group 3 was the largest group, with 38.6% (1,682/4,356) of the cases, followed by Group 1, with 30.8% (1,342/4,356), and Group 5, with 10.3% (450/4,356). Considering the contribution to overall CS rates per group, Group 5 contributed with 30.4% (345/1,136) of the CSs and within this group, 286/345 (82.9%) had 1 previous CS, with a CS rate > 70%. Groups 1 and 3, with 26.6% (291/1,136) and 13.5% (153/1,136), respectively, were the second and third larger contributors to the CS rate. Groups 2a and 4a had high induction success, with low CS rates (18.4 and 16.9%, respectively). Conclusion The RTGC is a useful tool to assess CS rates in different healthcare facilities. Groups 5, 1, and 3 were the main contributors to the CS rate, and groups 2 and 4 showed the impact and importance of induction of labor. These findings may support future interventions to reduce unnecessary CS, especially among primiparous and in women with previous CS.

The National Commission Specialized in Vaccines of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) endorses this document. The production of content is based on scientific evidence on the proposed theme and the results presented contribute to clinical practice. Article published online: 10 October 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Competency-based training emerged in the early 2000s and stands out as the primary internationally recognized guidance model for undergraduate and postgraduate (PG) training.[1] The knowledge, skills, and attitudes expected from physicians and specialists were established in competencies frameworks. In Brazil, the Medical Residency Commission (COREME) of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) led the development and validation of the Competency Framework in Gynecology and Obstetrics,[2] and subspecialties of Fetal Medicine, Human Reproduction, Sexology, and Gynecological Endoscopy.[1] However, the many subcomponents described in the Frameworks make it impossible for preceptors and supervisors to assess them throughout PG training.[3] To facilitate training and assessment of PG trainees, these competencies, which are attributes of an individual, had to be transformed into clearly observable and verifiable activities by preceptors and supervisors.[4] In 2007, these activities were identified as Entrustable Professional Activities (EPAs).[4] An EPA is defined as “a unit of professional practice that can be fully entrusted to an apprentice (PG trainee or medical student) when he demonstrates the necessary competencies to perform it independently and without supervision.”[1] A unit of practice can refer to a single task or activity (such as clinical examination of a pregnant woman or repair of a perineal tear) or to a set of tasks or activities (such as antenatal care or care for normal-risk delivery) undertaken by the apprentice physician that can be assessed by their preceptor or supervisor. Proficiency in performing each EPA, or unit of practice, becomes a prerequisite to authorize the apprentice or PG trainee to undertake it autonomously or independently of supervision, which is a process called entrustment.[1] The competencies required to perform each EPA do not need to be assessed individually. Entrustment in each activity presupposes the acquisition of knowledge, skills, and attitudes described in the Competency Framework, which enables and facilitates the PG trainee assessment by preceptors and supervisors.[5] In 2021, Febrasgo developed the Brazilian EPAs in Gynecology and Obstetrics at a national level, and this work was led by COREME. The chosen methodology was the Panel of Experts, as established in the literature and used in the development of the Competency Framework in Gynecology and Obstetrics.[2] [6] Based on national and international references,[2] [7] [8] [9] COREME/Febrasgo defined and validated 21 EPAs for the specialty of Gynecology and Obstetrics in Brazil. This comprehensive and detailed work involved more than 250 experts in different specialty areas. Therefore, the Gynecology and Obstetrics EPAs should guide PG trainees' entrustment in this specialty. The titles chosen for the 21 EPAS were: Promoting Prenatal Care for Low-Risk Pregnancies, Promoting Prenatal Care for High-Risk Pregnancies, Promoting Birth Care for Low-Risk Pregnancies, Promoting Birth Care for High-Risk Pregnancies, Promoting Postpartum Care, Promoting Care in Obstetric Emergencies, Promoting Care in Gynecological Emergencies, Promoting Care in Infectious Diseases, Promoting Care in Premalignant Genital Tract Lesions, Promoting Care in Gynecologic Oncology, Promoting Care in Mastology, Promoting Care in Pelvic Floor Disorders, Promoting Care in Chronic Pelvic Pain, Promoting Care in Abnormal Uterine Bleeding, Promoting Care in Contraception and Reproductive Planning, Promoting Care in Gynecologic Endocrinology, Promoting Care for the Infertile Couple, Promoting Care in Child and Pubertal Gynecology, Promoting Care in Climacteric and Senescence, Promoting Care in Sexual Dysfunctions, and Promoting Care in Violence Against Women.[10] The entrustment of PG trainees in performing EPAs is essential to ensure patients' safety, as it restrains autonomous medical activities and procedures only to the qualified ones. Therefore, it prevents trainees who have not yet acquired proficiency in these activities from performing care or decisions for which they are still not adequately prepared.[1] [4] [5] Through the development and validation of EPAs, Febrasgo enhances medical education and opens new perspectives to qualify the training of professionals who will care for women's health in Brazil. Received: 06 July 2022 Accepted: 25 July 2022 Article published online: 10 October 2022 © 2022. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

Objective: To evaluate the effect of neuromodulatory drugs on the intensity of chronic pelvic pain (CPP) in women. Data sources: Searches were carried out in the PubMed, Cochrane Central, Embase, Lilacs, OpenGrey, and Clinical Trials databases. Selection of studies: The searches were carried out by two of the authors, not delimiting publication date or original language. The following descriptors were used: chronic pelvic pain in women OR endometriosis, associated with MESH/ENTREE/DeCS: gabapentinoids, gabapentin, amitriptyline, antidepressant, pregabalin, anticonvulsant, sertraline, duloxetine, nortriptyline, citalopram, imipramine, venlafaxine, neuromodulation drugs, acyclic pelvic pain, serotonin, noradrenaline reuptake inhibitors, and tricyclic antidepressants, with the Boolean operator OR. Case reports and systematic reviews were excluded. Data collection: The following data were extracted: author, year of publication, setting, type of study, sample size, intervention details, follow-up time, and results. Data synthesis: A total of 218 articles were found, with 79 being excluded because they were repeated, leaving 139 articles for analysis: 90 were excluded in the analysis of the titles, 37 after reading the abstract, and 4 after reading the articles in full, and 1 could not be found, therefore, leaving 7 articles that were included in the review. Conclusion: Most of the studies analyzed have shown pain improvement with the help of neuromodulators for chronic pain. However, no improvement was found in the study with the highest statistical power. There is still not enough evidence that neuromodulatory drugs reduce the intensity of pain in women with CPP.