Outcome and efficacy of a transobturator polypropylene mesh kit in the treatment of anterior pelvic organ prolapse.

OBJECTIVE: To report the efficacy and complications of anterior pelvic organ prolapse (POP) repair with mesh placed through the transobturator route (Perigee system; AMS, Minnetonka, MN, USA). METHODS: In total, 198 women with anterior POP grade II or higher according to the POP Quantification (POP-Q) system were treated with the Perigee procedure. The primary outcome was defined as anterior POP grade I or lower at 12 months' follow-up. The secondary outcomes included the incidences of perioperative, mesh-related, short-term, and long-term postoperative complications. RESULTS: The cure rate was 92.9% overall and 90.6% among women who had previously undergone a hysterectomy or a traditional anterior colporrhaphy. The mean POP-Q Aa and Ba values were significantly improved after the procedure (Aa 2.2 cm [0.0 to 3.0 cm] versus -2.1cm [-3.0 to -1.2 cm]; Ba -2.5 cm [-1.0 to 4.2 cm] versus -2.2 cm [-5.5 to -1.0 cm]; P<0.001). Vaginal or bladder erosions were observed in 3 patients. Other short- and long-term complications were infrequent and not statistically significant. CONCLUSION: The Perigee procedure is effective in the treatment of anterior POP and does not have serious complications even among women with previous hysterectomy or traditional anterior colporrhaphy.

Raised electrical uterine activity and shortened cervical length could predict preterm delivery in a low-risk population.

PURPOSE: To compare diagnostic accuracy of sonographic cervical length (CL) measurement and uterine electric activity assessed by electromyography (EMG) in second trimester regarding prediction of preterm delivery (PTD). METHODS: Prospective study of 308 low-risk women. Shortened CL was defined as ≤25 mm (≤5th centile), while raised EMG activity was defined as the presence of ≥20 action potentials in 20 min of assessment (≥95th centile). Outcome measures were diagnostic accuracy of both tests alone or in combination for prediction of PTD and early PTD (≤34 weeks). RESULTS: The incidence of PTD was 23/308 (7.4%) while the incidence of early PTD was 9/308 (2.9%). Shortened CL and raised EMG activity were significantly related to PTD [prevalence-weighted likelihood ratio (pw-LR) 1.9, 95% CI 1.0-3.5 vs. 9.5, 95% CI 2.5-35.7], but not to early PTD (pw-LR 0.4, 95% CI 0.2-0.8 vs. 0.6, 95% CI 0.3-1.7). Significant predictive value for early PTD was found only if both tests were combined (pw-LR 4, 95% CI 1.3-14.3). CONCLUSION: Shortened CL and raised EMG activity in second trimester have significant diagnostic accuracy regarding prediction of PTD in a low-risk population. However, in order to be useful as a predictor for early PTD both tests must be positive.

Vaginal pH versus cervical length in the mid-trimester as screening predictors of preterm labor in a low-risk population.

OBJECTIVE: To assess the accuracy of a sign of bacterial vaginosis and a sign of cervical insufficiency in predicting preterm labor (PTL, occurring in the 37th week or earlier) and early PTL (occurring in the 34th week or earlier) in a low-risk cohort of 316 pregnant women. METHOD: Vaginal pH was assessed using test gloves and cervical length (CL) was measured by transvaginal ultrasound. A pH value less than 5.0 (the 95th-percentile threshold) and a CL greater than 26 mm (the 5th-percentile threshold) were considered normal. RESULTS: There were 14 participants (4.4%) with an elevated vaginal pH and 15 (4.7%) with a shortened CL. The incidence of PTL (<37 weeks) was 7.2%, while incidence of early PTL (≤34 weeks) was 2.5%. A shortened CL was significantly correlated with PTL (likelihood ratio [LR] weighted by prevalence; 2.7; 95% CI, 1.1-6.7) but not with early PTL (LR, 0.8; 95% CI, 0.4-1.8). An elevated vaginal pH was a better predictor of PTL (LR, 3.7; 95% CI, 1.3-10.4) and early PTL (LR, 1.7; 95% CI, 1.1-3.1). CONCLUSION: An elevated vaginal pH was a better predictor of early PTL than a shortened CL in this cohort of pregnant women at low risk.

Successful pregnancy and delivery of two sets of monozygotic twins after intracytoplasmic sperm injection and embryo transfer: case report and literature review.

OBJECTIVE: To report a unique case of successful pregnancy and delivery of two pair of monozygotic twins (quadruplets) after intracytoplasmic sperm injection (ISCI) and transfer of two blastocysts. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 30-year-old nulligravida, who had first ISCI, assisted hatching, and fresh embryo transfer because of a male factor of infertility (severe olygoasthenozoospermia). INTERVENTION(S): Prophylactic cervical cerclage sec. McDonald in the 21st week of pregnancy, hospitalization, and intensive care of pregnancy, ending with delivery by planned Cesarean section (CS) in the 34th week of pregnancy. MAIN OUTCOME MEASURE(S): Successful pregnancy and delivery of two male and two female twins in the 34th week of pregnancy. RESULT(S): Two blastocysts were divided and four embryos developed. After extensive counseling the couple decided to keep all embryos. In the 21st week prophylactic cerclage was preformed. During hospitalization the ultrasound examination was performed every 2 weeks, and from the 30th week on a cardiotocogram was recorded. At the 33rd week her blood pressure increased and she received antihypertensive therapy. At the 34th week planned CS was performed and four newborns (two male monochorionic monoamniotic twins, and two female monochorionic biamniotic twins) weighted between 1,300 and 2,170 g were born. CONCLUSION(S): Even without embryoreduction, intensive care throughout pregnancy including prophylactic cerclage, bed rest, prophylactic anticoagulant, and antihypertensive therapy results in delivery of four healthy newborns.

Diagnostic accuracy of sonographic and clinical parameters in the prediction of retained products of conception.

OBJECTIVE: The purpose of this study was to assess the diagnostic accuracy of different parameters (clinical and sonographic) in the prediction and management of retained products of conception (RPOC) in the late postpartum period. METHODS: This was a prospective cohort 3-year audit. Predefined data were collected and compared with histopathologic (HP) reports after uterine evacuation. The primary outcome measure was the diagnostic accuracy of different clinical and sonographic parameters, including color Doppler imaging in diagnosis of RPOC confirmed on HP reports. Secondary outcome measures were complication rates influencing maternal morbidity. RESULTS: In total, 93 patients (0.92% of all deliveries) were selected. The presence of gestational tissue was confirmed on HP reports in 58% of cases. The likelihood ratio of sonography alone was 1.47 (95% confidence interval, 1.25-1.84), whereas that of sonography combined with color Doppler imaging was 2.16 (1.3-3.59), providing statistically significant accuracy regarding the prediction of RPOC. CONCLUSIONS: Sonography alone or combined with color Doppler imaging has better diagnostic accuracy than the usual clinical parameters used for the prediction of RPOC.

Hyperreactio luteinalis could be a risk factor for development of HELLP syndrome: case report.

OBJECTIVE: To report a unique case of hyperreactio luteinalis in pregnancy associated with ovarian torsion and subsequent development of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 34-year-old primigravida woman with ovarian torsion in 13 weeks of pregnancy and subsequent intrauterine growth restriction (IUGR) and HELLP syndrome. INTERVENTION(S): Laparoscopic salpingo-oophorectomy due to the ovarian torsion and cesarean section (CS) due to the development of HELLP syndrome. MAIN OUTCOME MEASURE(S): HELLP syndrome. RESULT(S): In the first trimester the patient had symptoms of acute abdomen due to the ovarian torsion. Both ovaries were enlarged and multicystic. Hormonal studies confirmed an abnormally elevated level of hCG (192.000 IU/L), mild hyperthireosis, and hyperandrogenemia. Laparoscopic salpingo-oophorectomy was performed. At 30 weeks of pregnancy, IUGR was confirmed sonographically and clinically, and at 33 weeks severe preeclampsia developed. One week later, HELLP syndrome occurred. Emergency CS was preformed, and she delivered a female newborn weighing 1,640 g. Seven days after delivery, blood pressure and hormonal status returned to normal. CONCLUSION(S): Hyperreactio luteinalis due to the abnormally high level of hCG in the first trimester could be a consequence of inappropriate trophoblast invasion and an early sign of subsequently developing preeclampsia, eclampsia, and HELLP syndrome.

Uterine electrical activity and cervical shortening in the midtrimester of pregnancy.

OBJECTIVE: To determine whether a correlation exists between increased uterine electrical activity and cervical length (CL) in the midtrimester of pregnancy. METHOD: In this case-control study, 312 asymptomatic nulliparous women underwent both uterine electromyographic assessment and ultrasound CL measurement between the 16th and 23rd weeks of a singleton pregnancy. The outcome measure was the difference in ultrasound CL measurement between the women found to have uterine action potentials on electromyography and those who did not. RESULTS: Action potentials were detected in 66 (21.1%) of the 312 women; and compared with the remainder of the study population, cervical length was significantly shorter in these women (35.7+/-8.9 mm vs 38.8+/-7.9 mm; P<0.01 by the Mann-Whitney test). CONCLUSION: Ultrasound CL measurement in the midtrimester was significantly shorter in women with increased uterine electrical activity.

[Dillema about the method of delivery for the fetus in breech presentation]. / Dvojbe o nacinu porodaja ploda u stavu zatkom.

The management of preterm and term delivery of fetus in breech presentation is one of the most disputable issues in modern obstetric practice. Several years ago, one of the biggest randomized controlled studies in obstetrics, Term Breech Trial (TBT), tried to set up guidelines and resolve the question of the best method to deliver the fetus at term in breech presentation. The results of this study have shown that the policy of planned cesarean section reduces the risk of short-term adverse perinatal outcome, compared with the policy of planned vaginal birth. Many perinatal centers have accepted the recommendations from this study and different obstetric associations have implemented these results in their guidelines. On the other hand, TBT had some limitations, especially those connected with the impossibility of regular and objective comparison of these two methods of delivery. In addition, the same group of authors did not find differences in long-term outcomes between the planned cesarean section and vaginal delivery. Although the rate of planned cesarean section has increased following the publication of TBT, selective vaginal breech delivery is still very successfully used in the centers where doctors have the possibility to obtain experience in vaginal breech deliveries. The most common method of reduce the noncephalic presentation is external cephalic version at term. It reduces the incidence of noncephalic presentations at labor, thus reducing the number of cesarean sections as well. At this moment, there is not enough evidence to support cesarean section as the method of choice for delivery of preterm and term breech, having in mind obstetric indications and criteria. The decision whether to deliver vaginally or by cesarean section should be individual for each pregnant woman.

Is sonographic assessment of cervical length better than digital examination in screening for preterm delivery in a low-risk population?

BACKGROUND: This randomized controlled trial compared the diagnostic accuracy of the sonographic assessment of cervical length and clinical digital examination of the cervix in the second trimester regarding the prediction of preterm delivery in a low-risk population. METHODS: In total, 282 unselected, asymptomatic women with singleton pregnancy randomly underwent sonographic cervical length measurement (study group, n=138) or clinical digital examination (control group, n=144) in the second trimester. In the study group cervical length or=95th percentile (>or=4) for our population was defined as high. The primary outcome measure was the diagnostic accuracy of both tests regarding the prediction of preterm delivery (<37 weeks). RESULTS: Shortened cervical length was found in 6/138 (4.3%) women whereas the high Bishop score was found in 17/144 (11.8%) (p=0.038, Fisher's exact test). The incidence of preterm delivery was 5.7% (16/282). Regarding the prediction of preterm delivery, shortened cervical length and high Bishop score had sensitivity 57.1% versus 33.3% and positive predictive value 66.7% versus 17.6%. Shortened cervical length in comparison with high Bishop score had 12-fold higher positive likelihood ratio for preterm delivery in a low-risk population (37.4; 95%CI [8.2-170.7] versus 3.2; 95%CI [1.1-9.2]). CONCLUSION: Sonographic assessment of cervical length has better diagnostic accuracy in the prediction of preterm delivery compared to digital examination in a low-risk population.

Qualitative glandular cervical score as a potential new sonomorphological parameter in screening for preterm delivery.

This study compared diagnostic accuracy of sonographic assessment of cervical length (CL) and qualitative glandular cervical score (QGCS), in the second trimester regarding the prediction of preterm delivery (PTD) in the low-risk population. Cervical length < or = fifth percentile for our population was defined as shortened. The parameters evaluated in QGCS were: cervical mucus area and deepest invasion of cervical glands, and score < or = fifth percentile for our population was defined as low. Shortened CL was found in 6.1% whereas the low QGCS was found in 5.5%. The incidence of PTD < 34 completed wk was 2.1%, and between 34 to 37 wk it was 3%. Low QGCS in comparison with shortened CL had twofold higher likelihood ratio (LR) (23; 95% CI [12 to 43] versus 11; 95% CI [5 to 25]) for PTD < 34 completed wk and fourfold higher LR (12; 95%CI [5 to 28] versus 3; 95% CI [1 to 13]) for PTD between 34 to 37 wk. Low QGCS has the same if not better accuracy in comparison with shortened CL regarding the prediction of PTD in the low-risk population.

Ritodrine in oral maintenance of tocolysis after active preterm labor: randomized controlled trial.

AIM: To assess the efficacy of oral ritodrine in the form of sustained-release capsules for maintenance of uterine quiescence after successful treatment of threatened preterm labor. METHODS: We randomized 120 women with singleton pregnancy who were successfully treated for threatened preterm labor before 34 completed weeks to receive either maintenance tocolysis with two 40 mg ritodrine sustained release capsules three times a day (study group, n=62) or no treatment (control group, n=58) for three days. The primary outcome measure was the recurrent episode of threatened preterm labor within 72 hours, which was defined as regular palpable uterine contractions and change in cervical effacement or cervical dilatation on clinical examination. Secondary outcome measures included the incidence of preterm birth, neonatal adverse outcomes, and maternal side effects. RESULTS: There was no difference in the frequency of recurrent episodes of threatened preterm labor requiring another course of intravenous treatment between the study (8/62) and control (6/58) group of women (P=0.879). No differences were found between the study and control groups in any of the predefined secondary outcome measures, ie, delivery before 37 weeks (13/62 vs 7/58, respectively; P=0.288), delivery before 34 weeks (3/62 vs 1/58, respectively; P=0.682) and birth weight (3037-/+573 g vs 3223-/+423 g, respectively, P=0.862). There were more reported maternal side effects in the study group than in control group (47/62 vs 23/58, respectively; P(<0.001). CONCLUSIONS: Additional maintenance ritodrine therapy was unnecessary in women with singleton pregnancy who had an episode of threatened preterm labor successfully treated with intravenous tocolytic therapy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00290173.

Placental site does not change background uterine electromyographic activity in the middle trimester of pregnancy.

OBJECTIVE: This study was performed in order to assess the potential influence of placental implantation site on transabdominal electromyographic (EMG) assessment of the uterine electrical activity in the middle trimester of pregnancy. STUDY DESIGN: In this prospective study 251 unselected, nulliparous asymptomatic women with a singleton pregnancy underwent transabdominal uterine EMG. Uterine electrical activity was recorded using bipolar electrodes placed on the abdominal surface for 20min. Regarding the placental implantation site and presence of action potentials (AP) pregnant women were divided into two groups: the anterior placenta group (APG) and the posterior placenta group (PPG). Outcome measures were differences in the median frequency (MF) and median amplitude (MA) of AP between the two groups. RESULTS: Action potentials were detected in 56 women: 33/56 in the APG versus 23/56 in the PPG. The parameters analyzed (MF, p=0.527, Fisher's exact test, and MA, p=0.255, Fisher's exact test) did not produce any statistical significant differences between the two groups. CONCLUSION: Background uterine EMG activity measured from the abdominal surface in the middle trimester of pregnancy does not depend on the placental implantation site.

Diagnosis and management of Rh alloimmunization.

OBJECTIVE: To assess the current problem of alloimmunization in a tertiary referral center in Croatia. The results obtained were compared to data published worldwide. METHODS: Retrospective case analysis included women with Rhesus (Rh) alloimmunization treated in our department from January 1997 to January 2003. Data of interest included the incidence, prevention, diagnosis and treatment, with the final point being perinatal mortality and morbidity. RESULTS: 23 pregnant women with alloimmunization were identified. The incidence was 0.138% of deliveries in the same time period. The median gestational age at diagnosis/referral was 22 (range 9-37) weeks. Anti-D antigen, alone or in combination with the other antigens, was responsible for more than 90% of the alloimmunization cases included. A defined protocol for prevention of Rh D immunization after previous delivery was not followed properly in 9/19 cases. A particular problem was prophylaxis after previous pregnancy termination (TOP), whereby only 1/14 woman received adequate prophylaxis and only after 2 of 5 TOPs. Regarding fetal treatment, 9/23 women had a total of 24 intrauterine intravascular blood transfusions. Overall, perinatal mortality was 13%, and the median gestational age at delivery was 34 (range 31-40) weeks. In all there were 31 fetal exchange transfusions after delivery performed in 14/20 newborns. CONCLUSION: Despite precise diagnostic criteria and modern therapeutic options, alloimmunization remains a problem in Croatia. It is still related with a high perinatal mortality and morbidity. The main problem is inadequate prevention.

Predictive values of ultrasound monitoring of the menstrual cycle.

PURPOSE OF REVIEW: This review summarizes the current knowledge about ultrasound scanning values in monitoring the structural and functional changes of the uterus and ovaries during the menstrual cycle. RECENT FINDINGS: The views that ovulation is more frequently right sided have been challenged, with recent data suggesting that ovulation occurs randomly. A 'follicular wave phenomenon', providing a new model for ovarian function during the menstrual cycle, has been described. Follicular development occurs in a wave-like fashion and women with two waves have earlier endometrial development due to earlier increase of the dominant follicle estrogen production. Myometrial contractions during menstrual cycle should be considered in the assessment of endometrial thickness. Uterine-ovarian arterial blood flow impedance is important in understanding the normal physiology of the menstrual cycle and may be of use in assisted conception protocols. SUMMARY: At present, ultrasound scanning has an important role in noninvasive assessment of endometrial and ovarian cyclical changes and may be of particular importance in assisted conception procedures. Further work is likely to help in understanding its full diagnostic potential.

[Dilemmas about the antenatal use of corticosteroids for prevention of neonatal morbidity and mortality]. / Dvojbe antenatalne primjene kortikosteroida u svrhu prevencije novorodenackog pobola i smrtnosti.

Neonatal respiratory distress syndrome (RDS) is one of the biggest problems in modern obstetrics. The incidence of RDS is 1%-2%. RDS is a condition of insufficient surfactant production. Surfactant is a complex molecule which is responsible for maturation of fetal lungs. The most important factor for insufficient surfactant production and pulmonary immaturity is shortening of gestation, i.e. preterm delivery. Antenatal corticosteroids for maturation of fetal lungs are in use for over thirty years. Corticosteroids decrease the incidence and intensity of RDS, the severity of intracerebral hemorrhage, and overall neonatal morbidity and mortality. The mechanism of corticosteroid action is probably induction of fetal pulmonary enzyme complex that is responsible for adequate surfactant production and regulation of pulmonary interstitial fluids. In this literature review, we analyze long- and short-term benefits and risks of single and multiple antenatal corticosteroid administration.

[Diagnosis and therapy of cervical insufficiency]. / Dijagnostika i terapija cervikalne insuficijencije.

Cervical insufficiency is one of the risk factors for late spontaneous miscarriage and preterm labor. As cervical insufficiency can reoccur in the every subsequent pregnancy, there is a need for precise diagnostic modality and therapeutic procedure in order to reduce perinatal mortality and morbidity. Traditionally, the diagnosis of cervical insufficiency was made based on the patient's history. In this cases the intervention in the form of the cervical cerclage, was not found to be useful, i.e. perinatal mortality and morbidity remained unchanged. It is a similar situation in cervical insufficiency suspected based on hysterosalpingography and clinical examination. Recently, ultrasound, or more precisely transvaginal cervical assessment--cervicometry, was introduced in order to assess the morphological changes indicative for cervical insufficiency. In this literature review, we analyzed ultrasound based markers of cervical insufficiency, with their specificity, sensitivity, positive and negative predictive value, as well as usefulness of cervical cerclage in such cases.