Vaginal delivery and continuous epidural analgesia: should we change our clinical approach?

The aim of the study was to investigate the effects of continuous epidural analgesia (EA) on the course of vaginal delivery with an emphasis on duration of labor and instrumental interventions. In a prospective 2-year trial, the study group included singleton vaginal births between 35 and 41 gestational weeks with a vertex fetus, in which continuous EA with bupivacaine or chirocaine in concentration of 0.125% combined with 2-4 microg of fentanyl or 0.5 microg of sufenta was used. The control group was created randomly from laboring patients with singleton pregnancies but without EA. The groups were adjusted for epidemiological characteristics and compared regarding the obstetric data and perinatal outcome. Student t-test and Mann-Whitney U-test were performed for normally and non-normally distributed results, respectively. Out of 1284 patients, 551 pregnant women were included in the study group and 733 in the control group. The statistically significant differences between the groups related to duration of the first and second stage of labor, frequency of premature rupture of membranes, intrapartal complications, and incidence of operative deliveries were found. Both stages of labor were significantly protracted and the incidence of operative deliveries was higher in the study group of patients compared with controls. There is a need for an active obstetric approach and management of vaginal deliveries of women who receive continuous EA, particularly if it is medically indicated.

Medical and bioethical issues in a pregnant woman with epilepsy: case report.

A case report of a minor, pregnant girl with epilepsy caused by a brain tumour is presented. There are several aspects which make the presented case complex from medical, but also from the bioethical point of view. The decision about keeping the pregnancy or not is the most important bioethical dilemma for the patient and family. A detailed medical multidisciplinary approach and later balanced explanation of the medical situation to the patient are of extreme value for helping the patient's decision. It is also important to enhance the activities in pregnancy counselling for a woman with epilepsy which will result in a planned pregnancy as a prerequisite for a positive pregnancy outcome.

Villoglandular papillary adenocarcinoma of the uterine cervix with aggressive clinical course--a case report.

Villoglandular papillary adenocarcinoma (VGA) of cervix is an uncommon but well recognized histologic subtype of cervical adenocarcinoma which usually affects young women. Based on the favorable outcomes reported in most previous cases the tumor is generally considered to have an indolent clinical course with excellent prognosis. We present a case of a 22-year-old woman admitted at our Department for glandular abnormality on cervical smear and episodes of vaginal discharge. In the Pap smear, the cytological features were suspicious but not diagnostic of adenocarcinoma, therefore reported as atypical glandular cells (AGC). Histological examination confirmed VGA associated with lymphovascular space invasion. The patient underwent radical operative procedure. Intraoperative cytologic examination detected pelvic lymph nodes metastasis. The patient was confirmed to be in an advanced stage - III B (FIGO). During a two years follow-up period a rapid dissemination of the tumor occurred and resulted with a fatal outcome. Although VGA has been reported to have a favorable prognosis, several cases with lymph node involvement have already been described. Cervical smears examination would be helpful for an early diagnosis of VGA, however the cytologic recognition is often difficult. Further investigation of the pathogenesis, diagnosis and therapy of the tumor is needed.

[Epilepsy and pregnancy: antiepileptic drugs effects on pregnancy]. / Epilepsija i trudnoca--primjena antiepileptika u trudnoci.

PURPOSE: The aim of our study was to analyse the antiepileptic drugs (AEDs) usage in pregnant women with epilepsy, and to evaluate possible complications of this therapy during pregnancy and delivery as well as fetal effects of there drugs. METHODS: This retrospective study was conducted in the University Hospital Center Rijeka, Croatia, during the ten-year period (Jan 1, 1993-Dec 31, 2002). The study included 151 pregnant women with epilepsy. Data were entered in a structured form for evaluation of patient general data and data on antiepileptic therapy and neonatal outcome according to the use of AEDs. RESULTS: During the study period, 185 children (male 95) were born. Twenty-four miscarriages were recorded in women with the diagnosis of epilepsy in their medical history. In 117 of women, the onset of epilepsy occurred before the age of 20 years. AEDs were used in 111 of patients, in 77% of them as monotherapy. The most frequently used AEDs were carbamazepine (36.2%), valproate (29.3%), phenobarbitone (24.1%). Folic acid was used in 25 pregnancies only, however, during 2002 folic acid was used in 15 pregnancies (yielding 22 in total). Apgar score was equal or higher than 8/8 in 96% of children. No specific teratogenic effects were observed. CONCLUSION: Study results showed standard AEDs to be most commonly used in the study population, entailing no major birth defects, thus the potential risk probably being rather low. In the study population of pregnant women with epilepsy, the use of folic acid improved in 2002 in comparison to the previous period.