[IS THERE A PLACE FOR VIA AND VILI IN OUR PRACTICE].

UNLABELLED: The aim of this review is to discuss the possibilities and disadvantages of the techniques for visual inspection of the uterine cervix with acetic acid (VIA) and with Lugol's iodine (VILI) for early detection of cervical neoplasia. Efficient cervical screening method, approved in practice, is cytology--PAP smear. The lack of organized screening program in Bulgaria is the reason why a lot of cases of cervical cancer are missed or diagnosed late. This raises the question for searching alternative tests to assess the uterine cervix that do not use special techniques and have a reasonable cost. Published results show that VIA and VILI represent an appropriate alternative for cervical screening. The results of VIA and VILI are immediately available and do not require any laboratory processing. CONCLUSION: Both types of visual inspection of the uterine cervix are easy to accomplish, fast--the result is available at the moment of inspection, they do not require special equipment, the correlation between sensitivity and specificity is good and last but not least--they have low price. VIA and VILI have certain position in our practice.

[BOWEL ENDOMETRIOSIS - CASE OF RECTAL LOCALISATION.]

Endometriosis is a relatively common disease which rarely involves the bowel, and even more rarely occurs with intestinal obstruction. Gastrointestinal tract is involved in 3 to 37% of women with endometriosis such as the frequency is highest in the rectum and the sigma (72%), small intestine (7%), cecum (3.6%) and others. Our case concerns 49 years old woman with a picture of secondary intestinal obsruction, deepening during the last 2-3 months. An anterior resection of the rectum with the closure of the rectal stump has been performed with temporary colostoma - due to the severely inflamed and distended colon as a result of stenosis about 1 cm in diameter involving the portion from the Bauhin's valve to the rectal ampula, caused by two fist-sized tumors in the intestinal wall - on the rear and rear-left side of the rectum. Distally, about 2-3 cm of the tumors, on the anterior wall of the rectum have been found two plaque-like lesions, additionally. The histological result showed that the wall of the colon is engaged by transmural endometriosis, involving the mucosa, muskularis propria and serosa. The case presented differential diagnostic difficulties to exclude malignancy. The benefits of surgical treatment of intestinal endometriosis despite the significant volume of conducted surgery should not be underestimated, as with medication, it significantly improves clinical symptoms and quality of life.

[BENEFITS AND RISKS AT IMPLEMENTATION OF PROPHILACTIC VACCINES FOR CERVICAL CANCER].

The aim of this review is to present the benefits and risks of the implementation of prophylactic vaccines for cervical cancer. The classical understanding of human papilloma virus (HPV) infection and its role for the cervical oncogenesis, as well as, the place of prophylactic HPV vaccines are discussed. Results concerning the effectiveness of vaccines 10 years after their introduction and data about their safety are presented. Reports of the use in practice of the new 9-valent HPV vaccine and the first results of its implementation are studied.

[TREATMENT WITH INO OF INFANTS WITH PPHN.]

PPHN is a life threatening disease that appears as a result of high pulmonary vascular resistance and persistent right to left shunt across foramen ovale and ductus arteriosus. The treatment of PPHN is complex and often ineffective. iNO is important part of the pathogenetic treatment of the disease. We present six infants with PPHN treated with iNO. The clinical effect of the drug was quick and the hemodynamics stabilized. All infants survived without side effects and with better neurodevelopment outcome.

[CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETE DURING VAGINAL DELIVERY].

Conservative management of placenta accrete consists in leaving the entire placenta accreta in situ after vaginal delivery of the fetus. This behavior requires active monitoring the vital signs of mother, genital status and paraclinical indicators for an extended period after birth. Monitoring is suspended after full absorption of the placenta. The success of the conservative approach depends on: the adopted protocol formanagement of placenta accreta, whether the diagnosis is known before birth, the possible of application techniques, reducing blood flow to the uterus, keeping the placental period and others. The smallest success with vaginal birth, is when the diagnosis of placenta accreta is not know in advance and proceed with aggressive attempts to extract the placenta, followed by profuse bleeding from the uterus. As additional methods of securing conservative management is reported use of Methotrexate, with unproven effectiveness and embolization of a. Iliaca interna and a. uterine, which require a qualified team and have a lot of complications. Complications of conservative management of placenta accreta are: febrility and genital bleeding, which are the cause of late hysterectomy in about 35% of cases. lnfestion may be not always prevent by application of broad spectrum antibiotics. Late bleeding is usually associated with an active inflammatory process. Low-grade and low grade temperature increase of leukocytes and CRP may be due to necrotic changes in the placenta without the infection process. Tracking involution of the placenta is through abdominal and transvaginal ultrasound, magnetic resonance, using hysteroscopy through serial monitoring the level of hCG. From literature data the time for resorption of the placenta varies from 4 months to 1 year. It is essential to determine the time when it is safely to extract the placenta move in order to prevent late complications of conservative management. Our experience and some authors suggest that there may be instrumental extraction under ultrasound control at 8-10 days after birth.

[Histological subtypes of ovarian carcinoma and their importance for clinical prognosis].

Ovarian cancer is one of the most common and most lethal cancers. For Bulgaria (2012) it occupies third place in the structure of gynecological malignancies with a share of 22.6 percent, while regarding mortality is at first place with 35.7 percent. New cases are 838 with crude incidence 22.3 x 10(5), and the deaths are 463 with crude mortality 12.3 x 10(5). Ovarian tumors, even when they are of the same histological type clearly differ in their cellular differentiation, molecular characteristiques and subsequently in their biological behavior. In this review, we discuss the frequency origin, morphology and molecular characteristiques of the five major subtypes of ovarian cancer--serous low and high grade, mucinous, endometroid and and clear cell. The role of different risk and prognostic factors for the efficiency of the treatment and control of disease been discussed.

[Types of hospital property and the relative rate of cesarean section occurrence].

AIM: To determine the influential significance of types of hospital property over methods of delivery and other related medical issues METHODS AND MATERIALS: The research includes 61 662 deliveries over the period of 01.01.2013-31.12.2013, registered in the Birth Information System (BIS) maintained by the National Center of Public Health and Analyses . It is a retrospective research that compares the portion of cesarean sections (C-sections), premature births, the birth weight of newborns, and APGAR scores at the first minute after birth in three types of hospitals, divided by their property types--municipal, state owned, and private. Alternate analysis has been used--comparison of relative portion indices. We used t-test to determine significant differences among surveyed indicators with established level of significance p < 0.05. RESULTS: The rate of C-sections out of all deliveries for the period of 2013 totals 38.40%. One can determine important differences in this rate among different types of hospitals, the highest rate reaching 59.63% in private hospitals. Health institutions with more than 1000 deliveries per year also show a greater amount of accomplished c-sections. The percentage of birth before 37 weeks of gestation and of birth weight below 2500 g is greatest in state owned hospitals, and the portion of newborns with APGAR scores measuring above 7 is greatest in municipal hospitals. CONCLUSIONS: There is a tendency in the rise of the portion of c-sections, and from 2012 to 2013 this rise runs up to 2.39%. However, there is a lack of data to relate significant greater proportion of c-section deliveries in private hospitals to any medical reasons. Therefore, some additional research should be done to give a more objective explanation to the reasons as well as the consequences that follow a change in obstetrical behavior that eventually leads to a rise in c-section deliveries.

[CLINICAL PERFORMANCE OF DIFFERENT METHODS FOR CERVICAL SCREENING].

UNLABELLED: Cervical cancer is a serious medical and social issue as it affects women at active age and it is diagnosed too late. In Bulgaria morbidity and mortality show continuous increasing trend. The aim of this study is to compare the clinical performance of cytology and other alternative methods for cervical screening that could be used to assess the the cervix. MATERIAL AND METHODS: This is a prospective study which included 317 patients aged between 18 and 65 years. Women were divided into four groups: I-st--cytology, Il-nd--visual inspection with acetic acid (VIA), III-th--visual inspection with Lugol's iodine (VILI) and IV-th--spectrophotometric analysis with TruScreen®. The results showed that the most appropriate screening method for cervical cancer remains cytology. In the absence of cytological laboratory or cytopathologist spectrophotometric analysis with TruScreen® can be used for primary cervical screening. Its main advantages are that it is a real time technique, user easy and it is well accepted by women. If TruScreen is not available in the gynecologist's practice it is possible to perform visual inspection with acetic acid (VIA).

[MANAGEMENT OF PLACENTA ACCRETA, DIAGNOSED BEFORE BIRTH].

The optimal management of placenta accreta and until now remains unclear. The reasons for this are a rarity of this condition and the considerable heterogeneity of the group under the term "placenta accreta." Total hysterectomy during caesarean section is the most common approach to a known placenta accreta. Planned or emergency perinatal hysterectomy is associated with several complications--damage to the urinary tract, relaparotomiya, massive blood transfusions and stay in ICU. The average blood loss is about 3000 ml. To reduce blood loss in perinatal hysterectomy contribute: preliminary uterine artery occlusion, istmus-coporal longitudinal hysterectomy for extraction of the fetus, placental extraction along with the uterus. To save the woman's uterus at placenta accreta are using the following methods: cutting the uterine wall on which is located the placenta, imposing single stitches covering 2-3 cm in 1 cm, around the placental area; removal of the maximum possible part of the placenta; using longitudinal hysterectomy. So far, there are no comparative studies of the efficacy of different surgical techniques to preserve the uterus cases of placenta accreta. Extraction of the placenta to be done after the administration of uterotonics and devascularization the uterus. To reduce bleeding from the uterus after removal of parts of the placenta and according to the situation can be used: x-back hemostatic sutures from internal side of the uterus, tamponade with gauze roll, balloon catheters or haemostatic mushrooms. Conservative surgical treatment of placenta accreta is not always possible. In hospital Maternity Hospital-Sofia for the period 1986-2000 there were 17 cases of placenta accreta diagnosed only at birth. Maintaining the uterus was successful in 35% of these cases.

[PROLONGED RETAINED PLACENTA ACCRETA IN THE UTERUS AFTER VAGINAL DELIVERY (A CASE REPORT AND REVIEW OF LITERATURE)].

A case of prolonged retention in the uterus of placenta accreta after vaginal delivery is reported in the paper. The patient was 20 years old G3, P0 with two pregnancy terminations on request. She was admitted to the obstetric department of a regional hospital one day after the EDD with irregular contractions and non reassuring CTG. A few hours later intrauterine fetal demise occurred. Spontaneous labor commenced and a stillborn growth retarded fetus was delivered. Methergin was administered during the third stage of labor, but the placenta was not separated even after repeated Crede maneuvers, the last one under anesthesia. Since cervical spasm was present, the attempts for manual or instrumental separation of the placenta were unsuccessful. There was no genital bleeding, so further conservative approach was followed including continuous IV infusion of uterotonics, combined antibiotic therapy, close observation of the vital signs and the laboratory indicators. Three days after delivery the patient was transferred to a University Hospital because of subfebrile temperature. Her general condition on admission, although subfebrile, was good, there was no genital bleeding, the cervix was closed. The subfebrile temperatrure persisted despite antibiotic treatment; CRP was elevated (51,9 mg/l.). Because of suspicion for endomyometritis, on day 8th after delivery instrumental extraction of the placenta was undertaken with preparedness for hysterectomy in case of need. Although the procedure was difficult, with the placenta being extracted in parts, bleeding was scarce. The post operative period was uneventful and the patient was discharged from hospital five days after the intervention. A review of literature on the obstetric management of cases with retained placenta accreta after vaginal delivery is presented. The existing therapeutic options are discussed including their advantages and complications.

[110 years--University Obstetrics and Gynecology Hospital "Maichin dom"].

The first specialized Obstetrics and Gynecology Hospital in Bulgaria was founded based on the idea of Queen Maria Luisa (1883). Construction began in 1896 and the official opening of the hospital took place on November 19, 1903. What is unique about the University Obstetrics and Gynecology Hospital "Maichin dom" is above all the fact that the Bulgarian school of obstetrics and gynecology was founded within its institution. Currently, the hospital has nearly 400 beds and 600 employees who work at nine clinics and six laboratories, covering the entire spectrum of obstetric and gynecological activities. Its leading specialists still continue to embody the highest level of professionalism and dedication. The future development of the hospital is chiefly associated with the renovation of facilities, resources and equipment and with the enhancement of the professional competence of the staff and of the quality of hospital products to improve the health and satisfaction of the patients.

[New colposcopic terminology: Rio de Janeiro--2011].

The purpose of this work is to review the new colposcopic classification of the International Federation for Cervical Pathology and Colposcopy (IFCPC) from 2011 and the possibilities for its application in diagnostic and treatment processes and research. It fulfills the necessity for a modern and widely applicable nomenclature of the findings and it is based on the latest knowledge in this area. Colposcopic terminology of the vagina, as part of the pathology of the lower genital tract, is included as well, while the vulva and perineum terminology is not yet finally adopted. Furthermore, the various cervical excisional techniques are evaluated and described. According to experts, the popularity of colposcopy will not diminish and it will continue to be used as a routine technique in daily practice. In a critical sense, despite its descriptive and punctual character, the accepted terminology classification does not give a new interpretation of the severity of changes, and as such, it does not significantly modify the diagnostic and therapeutic approach. The lack of a scoring system that would allow the dynamic comparison of the severity of symptoms and the categories over time is a serious weakness. This limits the new colposcopic classification as no more than a working sheet that descriptively assesses the findings of the lower genital tract.

[Significance of some colposcopy signs as a marker for severity of histologic atypia].

We present the latest revision of colposcopic terminology accepted by IFCPC. The differences from the previous revision are represented. Colposcopic atypia encompasses a wide range of changes in the cervical mucosa. Therefore to drawa parallel between colposcopic findings and the severity of the histological changes in affected areas is difficult. The objective of the observers is to improve the accuracy of colposcopy as diagnostic method. For this purpose specific signs are searched that increase the degree of coincidence between colposcopic and histological atypia We present examples for the described markers "inner border sign" and "ridge sign", included in the latest nomenclature of IFCPC. Research results show the specificity of "inner border sign" and "ridge sign" for the detection of underlying CIN2/3 reaches 93.1% and 97% respectively. We have illustrated also the recently defined "rag sign" and "umbilication", which could be associated with high-grade CIN. Conclusion. Careful review of the lesion when there is a colposcopic atypia can detect features that guide the examiner to possibly severe changes and therefore have practical significance in selecting a suitable biopsy place and appropriate observing.

[Causes of stillbirths according to the period of pregnancy].

INTRODUCTION: Stillbirths represent 50% of all perinatal mortality and remain significant and unanswered problem. OBJECTIVE: To investigate the causes of stillbirths in term and preterm fetuses and place of intrauterine growth retardation in the pathogenesis of antenatal death. MATERIALS AND METHODS: The study was retrospective for the period 2008 to 2013, covers 217 cases of stillbirths in University Hospital "Maichin dom" Sofia. Gestational age was from 23 to 41 weeks. Inclusion criteria for the study were: antenatal occurred dead and singleton pregnancy. Exclusion criteria: fetal malformations and multiple pregnancies. Thus number of enrolled cases was 153. RESULTS: The causes of stillbirths are different in different groups according gestational age. The cases of unknown cause, abruption of placenta and preeclampsia prevail in preterm group. The term stillborns headed with pathology of the umbilical cord, followed by cases of unknown cause, diabetes and infection. Overall, preterm group stillborn with mass below 10 percentile for the gestational age - 53 % predominate, compared with those born at term - 39%. CONCLUSIONS: The incidence of stillbirths is higher in preterm than term born fetuses. The causes of antenatal death in preterm is mainly abruption of placenta and preeclampsia, whereas in term - pathology of the umbilical cord. In premature stillborn intrauterine growth retardation is more common in comparison with those on term. Unexplained antenatal fetal death is more common in preterm fetuses.

[Case of intrauterine retardation and fetal death during labor].

The case concerns to a 37 years old pregnant woman with a history of three miscarriages. Ultrasound biometry in early pregnancy corresponds to the term calculated according the last menstrual period (LMP). At 37 week of gestation was determined retardation of 5 weeks. Doppler velocimetry and quantity of amniotic fluid were in normal ranges and the pregnant refused hospitalization. She was admitted to the hospital three days after the appointed term without uterine contractions. The fetal ultrasound biometry meets 33 weeks and the Doppler examination of a. umbilicalis found resistance index (RI) of the upper limit of normal. The cardiotocography record shows: baseline fetal heart rate--143 beats/min, good variability and reactivity. There was one deceleration for 3 minutes, and then the recording returns to normal. Re-monitoring after 30 minutes establishes of a periodic decelerations and a tendency to bradycardia with reserved variability. At the start of the emergency Cesarean Section fetal heart beats are single. The delivered babe was with Apgar O. The reanimation was not successful and the fetus died. From the autopsy signs of severe asphyxia. In conclusion, it can be assumed that in strongly retarded fetuses, cardiotocography recording and Doppler velosimetry are not sufficiently reliable methods for continued monitoring. In late-onset and severe intrauterine growth retardation (IUGR) desirable delivery time is after reaching biological maturity at 36-37 week.

[Pregnancy and malignant diseases. Part V. Some rare gynecological tumors during pregnancy].

Neoplasia of the vagina, endometrium and fallopian tube have low frequency in pregnant women and in the literature have been reported occasionally. Symptoms of cancer during pregnancy is often ignored by patients and physicians, leading to delayed diagnosis. This publication examines some characteristics of clinical course and management of cases of pregnancy combined with such tumors. Early diagnosis and treatment are essential for the favorable prognosis of the disease as well as of the pregnancy.

[Diagnostic value of TruScreen, cytology and colposcopy].

UNLABELLED: The aim of this study was to compare the diagnostic value of TruScreen with that of already approved in practice methods for detection of precancerous conditions of the cervix. This study reviewed 301 patients; for analysis were included 260 women aged from 16 to 69 years, mean 35.82 years. They were divided into three groups. RESULTS: After statistical analysis of the results we found sensitivity of conventional Pap smear, colposcopy and TruScreen respectively 67.44%, 96.55% and 53.85%, and specificity respectively 83.93%, 45.90% and 78.79%. CONCLUSION: TruScreen is a representative of real time methods for cervical screening. Our results are close to the obtained in other studies: medium value sensitivity and high specificity of the method, which shows that there is a possibility for its use as a primary screening, and also in addition to cytology. TruScreen is especially suitable in places where no cytology laboratories and specialists are available. It is a quick method (result at the moment), does not require special qualification and long training of the operator (as opposed to colposcopy) and is well received by women. Sufficient number of cases remains to be collected for more accurate assessment of the potential of TruScreen. It is appropriate to identify if TruScreen has different diagnostic value in mild and severe cervical changes, and also its efficacy as a primary screening method and in combination with other already approved in practice screening methods.

[Screning study on pregnant women and neonatal infection with streptococcus agalactiae (group B streptococci)].

We report the results of a screening study on pregnant women and early onset neonatal group B streptococcal infections in Sofia, Bulgaria, July 2009-July 2010. Women were studied for risk factors at delivery, intrapartum antibiotic prophylaxis (lAP) and outcome for the newborns. All GBS positive women who had risk factors at delivery gave birth to newborns with neonatal infection despite the IAP given in 50% of the cases. The majority of the GBS positive women who had no risk factors at delivery gave birth to healthy newborns although only 32% of them received IAP However 11% of the GBS positive women without risk factors delivered children with neonatal infection. We consider that IAP should be given to all GBS positive women to prevent from neonatal infection. The dominant GBS serotypes were ll, 11 and la. The isolates were 100% susceptible to penicillin, cefazolin, cefotaxime, vancomycin and 91.66% susceptible to erythromycin and clindamycin, the resistant strains being from the MLSB phenotype.

[Pregnancy and malignant diseases. Part III--Ovarian cancer].

The frequency of ovarian tumors during pregnancy is from 1:81 to 1:328 and most of them are functional cysts. Ovarian cancer varies from 1:10 000 to 1:25 000 pregnancies. It presents 2-5% of all ovarian tumors in pregnant women. If ovarian cancer is detected it should be managed according to the stage of the disease, nevertheless of pregnancy. Chemotherapy during pregnancy is under discussion, due to the lack of randomized trials. All chemotherapeutic agents are potentially teratogenic, especially in the first trimester. Retrospective investigations of the implementation of chemotherapy in the second and third trimester did not show congenital anomalies, but in some cases there is a fetal retardation. If diagnosed early, ovarian cancer may have good outcome for mother and newborn.

[Pregnancy and malignant diseases. Part III--. Vulvar cancer].

Vulvar cancer is among the rarest gynecological tumors. It is extremely rare in pregnant women. In the scientific literature, data has been recorded for no more than 50 cases of vulvar cancer during pregnancy. The etiological and pathogeneteic role of the HPV infection is discussed. The early histological diagnosis and treatment of every vulvar neoplasia during pregnancy are preconditions for a favorable prognosis for the disease and the pregnancy likewise. The management for women with vulvar cancer and pregnancy needs to be determined by a multidisciplinary staff with obstetrician-gynecologists, oncologists and neonatologists, while the point of view of the patient also has to be taken into account.