The Determination of Fetal RhD Status from Maternal Blood in Serbia.

The aim of this research was to demonstrate: The specificity, sensitivity, the positive and negative prediction value of the PCR method in the detection of the fetal RhD status from maternal blood in various weeks of gestation. Which was the earliest gestational week, when is possible to get a reliable result? How did the presence of RhD antibodies in sensitized mothers affect the results? This was a prospective clinical study within a multidisciplinary project approved by the Ministry of Science of the Republic of Serbia, 2011. The study was approved by the Ethics Committee of the Medical Faculty in Belgrade. Ninety six RhD negative patients had participated in the study, with written consent. The sensitivity of the determination of the RhD status of the fetus from the mother's blood after the 7th GW in our sample was 98.6%, with a specificity of 92%. The positive predictive value of the test was 97% and the negative predictive value was 95.6%. False positive results were detected in 2.6% of cases and 4.5% of cases were false negative. This is a reliable test which should be used in monitoring of pregnancies of RhD negative mothers.

Fetal hydrops and middle cerebral artery Doppler in prediction degree of fetal anemia and the best timing for therapy.

PURPOSE: To determine the role of fetal multiples of the median of middle cerebral artery peak systolic velocity (MoM MCA-PSV), in predicting the degree of fetal anemia for determination of the best timing for the second intrauterine intravascular transfusion (IUIVT) in hydropic fetuses with Rh alloimmunization. MATERIALS AND METHODS: Prospective study of 30 monofetal pregnancies with maternal Rh D alloimmunization and hydrops fetalis, from 2005 to 2012 that underwent first and second IUIVT were assessed. RESULTS: Thirty IUIVT were performed at 26.9 weeks (standard deviation, SD 4.3). Mean interval to the second procedure was 11.23 (SD 6.21) days and average hematocrit decline rate was 1.45%/day. The study did not demonstrated statistical significance between MCA-MoM-3 before the second IUIVT, and the mean decline rate in fetal hematocrit levels (expressed in percentage/day) r = 0.220; p = 0.242, and between MCA-MoM-3 and the time interval between both procedures (T) r = -0.157; p = 0.408. CONCLUSION: The measurements fetal MoM-MCA before every IUIVT cannot be useful as predictor for the best timing for the next IUIVT, but it can be useful in predicting severity of fetal anemia.

The influence of obesity on abdominal cesarean section delivery.

AIM: The analyze the potential influence between obesity in pregnancy and the abdominal delivery-cesarean section and to establish the possibility of its prevention. MATERIALS AND METHODS: A prospective study examined 200 patients, delivered by cesarean section in a one-year period. The study included a structured questionnaire; the body weight at the end of pregnancy was measured and it was analyzed against all available medicine documentation. Statistical analysis included: chi2 test, Student's t-test, and Fisher's test, as well the Pearson's and Spearman's test of correlation rank. RESULTS: From all 200 (100%) patients delivered by cesarean section, 67 (33.5%) were overweight and obese. Body mass index at the beginning of pregnancy was significantly associated with cesarean section (chi2 = 69.141; p < 0.001), along with the appearance of eventual pregnancy complications, and also with the neonatal birth weight (p = 0.224; p < 0.001). CONCLUSION: The nutritive status, both at the beginning and at the end of pregnancy is the important factor for the pregnancy outcome.

Middle cerebral artery Doppler in prediction degree of fetal anemia and the best timing for the second intrauterine intravascular transfusion in red cell alloimmune disease.

AIM: To determine the role of fetal multiples of the median of middle cerebral artery peak systolic velocity (MoM MCA-PSV), predicts the rate of decline in fetal hematocrit (Hct) for determination of the best timing for the second intrauterine intravascular transfusion (IUIVT) in fetuses with Rh alloimmunisation. MATERIALS AND METHOD: Retrospective study of 59-monofetal alloimmunized pregnancies from 2005 to 2012 that underwent first and second IUIVT were assessed in Department of Gynecology and Obstetrics, Belgrade, Serbia. RESULT: There was an inverse statistically significant correlation between measurements MCA MoM-1 and fetal Hct-1 before the first IUIVT r = -0.622; p = 0.001 and MCA-MoM-3 and Hct-3 before the second IUIVT r = -0.381; p = 0.001, also as the significant correlation between the interval between both procedures (expressed in day) and measurement MCA-MoM-3, before the second IUIVT r = -0.284; p = 0.029. CONCLUSION: The measurements MoM-MCA before every IUIVT can be useful for prediction of the best timing for the next IUIVT.

Doppler assessment between pathological examination of the placenta and late fetal intrauterine demise.

AIM: The relation between placental histopathological examination, umbilical cord pathology and abnormal umbilical and cerebral Doppler as a predictor of stillbirth at later gestations was evaluated. MATERIALS AND METHODS: A retrospective study of 55 monofetal pregnancies complicated with late fetal death from 2005-2008 was conducted at the Institute of Gynecology and Obstetrics, Bel-grade. STATISTICAL ANALYSIS: chi-square likelihood ratio test and Spearman's coefficient correlation. RESULTS: Intrauterine fetal demise occurred most frequently at term -32.7% of the time. Changes in the umbilical artery resistance index were not significantly different from placental histopathology findings, p = 0.363. There was a significant correlation between neonatal birth weight and weeks of gestation at delivery, r = 0.796; p = 0.001. CONCLUSION: Umbilical artery Doppler is a relatively poor predictor of stillbirths due to placental dysfunction. It seems that neonatal birth weight is the best predictor of late stillbirth in high-risk pregnancies.

Vasa previa and postpartum hysterectomy in maternal Rh alloimmunization.

Velamentous insertion of the cord, or vasa previa, is a malady where fetal vessels tranverse membranes ahead of the fetal part. The incidence of vasa previa is 1: 2000-3000 deliveries. Fetal mortality is over 50-75%. Early diagnosis is needed because these deliveries require emergency cesarean section; it is especially more common with placenta percreta, uterine atony and hemorrhage. Intravascular infusion of red blood cells (RBCs) into the fetus is one of the most successful means of in utero therapy for severe fetal anemia caused by RBC alloimmunization. We performed four fetal intrauterine intravascular transfusions (IVT) as therapy for severe fetal anemia. The patient underwent elective cesarean section. After delivery, profound uterine atony and vaginal hemorrhage were noted and the patient underwent hysterectomy. Pathological examination of the placenta and umbilical cord documented velamentous insertion of the cord. Before intrauterine IVT a detailed US examination is necessary to exclude vasa previa or placenta previa. Uterine atony may be result after a diagnosis of placenta previa or vasa previa. Intrauterine IVT is an irreplaceable diagnostic procedure in the treatment of severe fetal anemia.

Intramuscular fetal corticosteroid therapy: short-term effects on the fetus.

OBJECTIVE: The aim of the study was to assess the short-term effects of direct intramuscular (i.m.) corticosteroid therapy on fetal biophysical profile, baseline fetal heart rate and the nonstress test, which indicate the degree of fetal hypoxia. METHOD: We evaluated the effect of direct i.m. fetal single-dose dexamethasone (4 mg/kg) on the fetal biophysical profile 2 h before and 2-4 h after corticosteroid therapy in 41 fetuses in the 32nd week of gestation at risk of preterm delivery. Risk factors for preterm delivery included pregnancy-induced hypertension and preeclampsia. RESULT: There was a statistically significant difference between fetal breathing movements before and after corticosteroid therapy (p = 0.019; 95% confidence interval for difference -11.75, -1.12). No significant changes were observed between baseline fetal heart rate before and after corticosteroid therapy (p = 0.99; 95% confidence interval for difference -4.81, +4.81), biophysical profile before and after fetal corticosteroid therapy, p = 0.235 as well as the nonstress test before and after therapy (p = 0.564). CONCLUSION: Direct corticosteroid i.m. fetal therapy results in increasing profound short-term fetal breathing movements. There are no changes in baseline fetal heart rate, biophysical profile score, and nonstress test.

Two cases of immature teratoma with positive reproductive outcomes.

The peak incidence of immature teratoma is in the early reproductive period of a woman's life and fertility preservation is an inevitable topic when discussing treatment options. We present two cases of immature teratoma with positive reproductive outcome. Our experience supports the standpoint that surgery alone is curative in most cases, irrespective of tumor grade. Bearing this in mind, the long-term effect of chemotherapy on ovarian function can be avoided and fertility, an important factor in the overall quality of life, can be preserved.

Antibodies detected in samples from 21,730 pregnant women.

Although anti-D is still the main cause of HDN, many other antibodies have been implicated. From September 1995 to April 2000,screening for RBC antibodies was performed on samples from 21,730 pregnant women regardless of RhD type. Standard tube and gel methods were used. Anti-D was identified in 254 samples; other antibody specificities were detected in 376 samples, for a total of 630 antibodies. For this study, 522 antibodies were considered clinically significant. The incidence of potentially clinically significant antibodies was 2.4 percent. The majority belonged to the Rh system, followed by anti-M, -Fya, -S, -Jka, and -Jkb. Among antibodies of no clinical significance, the most frequent were anti- H, -Lea, and -P1.

The Serbian version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Serbian language of the parentís version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Serbian CHAQ-CHQ were fully validated with 3 forward and 1 backward translations. A total of 139 subjects were enrolled: 79 patients with JIA (30% systemic onset, 28% polyarticular onset, 6% extended oligoarticular subtype, and 36% persistent oligoarticular subtype) and 60 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Serbian version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

[The role of nutritional factors in pre-eclampsia and eclampsia]. / Uloga cinioca ishrane na pojavu preeklampcije i eklampcija.

Preeclampsia and eclampsia are very important health problems because they are the main contributors to maternal and perinatal morbidity and mortality. These disorders are unique in pregnancy and are characterized by oedema, proteinuria and hypertension. they occur in 0.5% to 30% of all pregnancies, primarily in primigravidas, after the 20-th week of gestation. Preeclampsia and eclampsia are diseases of undetermined cause. Many different factors might play an important role in the development of these diseases. One of them is nutrition. Recent studies have emphasized the possible role of general nutritional deficiency or imbalance of several specific nutrients in the aetiology of the disease. Deficiency of a variety of nutrients has been reported in patients with preeclampsia. The obtained results are contradictory and further study is necessary. Nevertheless, some evidence is highly suggestive of a relationship between nutritional status and the onset or progress of the disease. The article reviews the study that correlates the role of several nutritional elements with the pathophysiology of preeclampsia and eclampsia: proteins, lipids, calcium, vitamin D, sodium, magnesium and zinc. The evidence that supports or rejects the role of each of these nutrients is presented. In this way a guideline for general nutritional counseling in the prenatal period that will promote a healthier pregnancy, is offered.

The role of beta-endorphin in pregnancy and delivery.

This paper deals with beta-endorphin determination in 20 autopsy specimens of human fetal and neonatal pancreas, as well as in the placental tissue specimens of the same fetoplacental units, by means of radioimmunoassay (RIA-Nichols Institute). Peripheral blood samples of 10 healthy non-gravids were taken as controls. Our results present a marked increase of beta-endorphin levels with the progression of gestation, reaching a peak of 3960 pg/g at term. The data obtained indicate that beta-endorphin plays an important role in pregnancy and delivery regulation.

Is there a link between beta-endorphin and diabetes in pregnancy?

The possible influence of both beta-endorphin and insulin secretion on diabetes development in pregnant women was studied by means of radioimmunoassay technique (RIA-Nichols Institute). The study was carried out by determination of beta endorphins in peripheral blood samples of 28 pregnant women with gestational diabetes. They consisted of two subgroups: 14 women with insulin independence, and 14 with insulin-dependent disease. Beta endorphin increase was found in both groups, according to the progression of gestation, and the rise was significantly higher in the insulin-dependent group. At the same time, insulin application caused a marked growth of beta-endorphins in insulin-dependent group. Beta-endorphins, inhibiting insulin secretion, can influence gestational diabetes development.

Risk estimation of intraamniotic infection development after serial amniocentesis.

Microbial invasion and growth in amniotic fluid play an important role in infectious perinatal morbidity and mortality. In order to determine the influence of amniocentesis (ACT) on intra-amniotic infection development, we performed a study of 239 complete microbiological examinations of amniotic fluid specimens obtained by serial interventions. In 1 case (0.42%), during the second procedure, Staphylococcus epidermidis was discovered. Neither spontaneous abortion nor preterm labor were provoked by the procedure. We can conclude that ACT has been confirmed as a safe and successful intrauterine intervention if it is made in a proper manner.

[Dietetic-hygienic measures in the control of arterial hypertension in obese females]. / Dijetetsko-higijenske mere u suzbijanju arterijske hipertenzije gojaznih osoba zenskog pola.

Since the evidence to data suggest that some obese person respond well to non-pharmacological measures, the aim of this study was to examine the extent of body weight reduction necessary to reduce blood pressure to normal values. A group of 250 obese women with hypertension (blood pressure measurements over 160/95) and an overweight of at least 20 per cent excess of ideal weight was included in the study. The patients were advised to take well balanced low-calorie (about 1000 kcal/day) diet containing 66 g proteins, 140 g carbohydrates, 13 g fat and 0.5 g salt. They were advised to increase daily physical activities. Low-calorie diets were used to decrease body weight in groups of patients with changed of unchanged antihypertensive drug therapy, also. Decrease in body weight resulted in significant decrease in blood pressure; over two-thirds of complaint patients achieve normal blood pressure with a loss of only 5-10 per cent of their weight excess even if at this point they were still overweight. In the group receiving no drug therapy 78 per cent reached normal blood pressure, 76 per cent in the patients whose antihypertensive treatment had to be modified during the study and 63 per cent in the group receiving unchanged drug therapy. It was concluded that weight reduction program (diet and physical activity) can be a possible approach to treat hypertension without drugs and patients can attain normotension long before achieving the ideal weight.

The severely anemic and hydropic isoimmune fetus: changes in fetal hematocrit associated with intrauterine death.

Hydrops caused by isoimmune hemolytic anemia is frequently associated with fetal death following intrauterine intravascular transfusion. To identify possible predictors of procedure-related fetal death, we examined changes in fetal blood volume and hematocrit resulting from the initial transfusion performed on 19 severely anemic, hydropic fetuses. Seven fetuses (36.8%) died at 24-72 hours after transfusion, but in no case was the procedure associated with fetal distress. There were no significant differences between fetuses who died and those who survived in terms of total volume of blood transfused, volume transfused as a percentage of total fetoplacental blood volume, hematocrit of transfused blood, post-transfusion hematocrit, umbilical vein pH, or gestational age at transfusion. Significant differences were noted between hydropic fetuses who died compared with those who survived in the mean pretransfusion hematocrit, 6.7% (+/- 2.0) versus 8.7% (+/- 1.6) (P = .03), and the relative increase in post- over pre-transfusion hematocrit, 5.5-fold (+/- 1.4) versus 3.5-fold (+/- 0.8) (P = .001). Stepwise logistic regression analysis confirmed that only the relative increase in hematocrit was predictive of fetal loss. Moreover, six of seven fetal deaths occurred when the relative increase in hematocrit was greater than fourfold, whereas ten of 12 surviving fetuses had relative increases of less than fourfold. We conclude that large, acute increases in fetal hematocrit following intrauterine transfusion are associated with substantial mortality in hydropic fetuses.

[Causes of mental health disorders during pregnancy and in the postpartum period]. / Uzroci poremacaja mentalnog zdravlja u trudnoci i posleporodjajnom periodu.

SUMMARY: Pregnancy, delivery and postpartal period are biological phenomena which are influenced by the interaction of numerous physiological, psychological and social factor. The psychological disturbance occurring in pregnancy not only affects the health of the mother, but also it influences the outcome of pregnancy and delivery, as well as the newborn infant. The literature describes various causes of such disturbances. Different schools point out psychodynamic, endocrinologic and psychosomatic causes respectively.

Intrauterine intravascular transfusion for severe erythroblastosis fetalis: how much to transfuse?

Intrauterine intravascular transfusion is now believed to be a more precise method for treating fetal anemia in erythroblastosis fetalis than is intraperitoneal transfusion. Previously established guidelines for the volume of blood to be given in intraperitoneal transfusion at a specific gestational age are not applicable for intravascular transfusion. In 28 patients, intravascular transfusion was performed on 81 occasions between 19-34 weeks' gestation. The total number of transfusions ranged from one to six per patient. The aim at each procedure was to achieve a final hematocrit of 35-50%. Factors examined as likely to determine the volume of blood required included pre-transfusion hematocrit, post-minus pre-transfusion hematocrit (hematocrit increase), the hematocrit of the transfused blood, gestational age, estimated fetal weight, and interval from last transfusion. The factors found to be most predictive of total volume of blood required for transfusion were the hematocrit increase and either estimated fetal weight or gestational age.