Depression, anxiety, and stress in infertile couples during the COVID-19 pandemic: the consequences we face.

OBJECTIVE: Postponing assisted reproductive technology treatment can cause pronounced mental health problems. The aim of this study was to examine the level of depression, anxiety, stress, and overall infertility-related distress experienced by infertile couples during the pandemic, as well as the differences between men and women in the examined variables and the correlations between them. METHODS: A total of 131 participants were included in the study, 65 men and 66 women. They were selected based on their responses in the Fertility Problems Inventory (FPI); the Depression, Anxiety, and Stress Scale-21 (DASS-21); and a general data questionnaire provided to them at the time of IVF. RESULTS: The levels of depression, anxiety, and stress in women and men resided within the normal range. Depression (p<0.05), anxiety (p<0.01), stress (p<0.01), and social concern (p<0.05) were more pronounced among women. Significant correlations were found between depression, anxiety, stress, and global stress and its three dimensions: social concern, sexual concern, and relationship concern. CONCLUSIONS: During the pandemic, women undergoing assisted reproductive technology treatment experienced significantly higher levels of depression, anxiety, stress, and overall infertility-related stress than men. Furthermore, depression, anxiety, and stress were apparently correlated with overall infertility-related stress.

Life satisfaction and anxiety in women with urinary incontinence.

BACKGROUND: This study aimed to examine satisfaction with life in patients with urinary incontinence and patients who underwent an operative procedure due to urinary incontinence. METHODS: Women with a medical indication for surgery due to urinary incontinence problems but who had not yet had surgery (N = 110) and same-age women who had had a surgical procedure for urinary incontinence (N = 101) completed a set of questionnaires. RESULTS: The results showed that women with urinary incontinence had significantly higher life satisfaction than women who underwent the operation. Contrary to expectations, women with urinary incontinence problems reported equal levels of life satisfaction to a comparable sample of postmenopausal normative women. Higher levels of life satisfaction were related to higher education level, employment, higher perceived socioeconomic level, and urban place of living. CONCLUSION: It is important for physicians to address the problem of urinary incontinence with their patients and to examine the present anxiety symptoms, given that they may affect their subjective wellbeing.

Ichthyosis uteri associated with squamous cell carcinoma of the endometrium - a case report.

BACKGROUND: Ichthyosis uteri is an extremely rare condition in which the entire or extensive parts of endometrial lining are replaced by stratified squamous epithelium. Malignant potential of this entity is unclear and its association with dysplastic changes and primary squamous cell carcinoma of the endometrium and endometrial adenocarcinoma has been reported. However, lack of data makes difficult to interpret the significance of neoplasms arising from this condition. PATIENTS AND METHODS: We report a case of ichthyosis uteri associated with squamous cell carcinoma of the endometrium in a 62-year-old female who presented with postmenopausal bleeding and thin endometrium on ultrasound. RESULTS: Endometrial curettage was performed and revealed high grade squamous intraepithelial lesion. The patient underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic lymph node dissection. Microscopic examination of sections revealed squamous cell cancer along with extensive replacement of the endometrial lining by stratified squamous epithelium, consistent with ichthyosis uteri. CONCLUSION: If ichthyosis uteri is suspected we recommend hysterectomy in order to rule out possibility of coexisting carcinoma. Also, thin endometrium in women with postmenopausal bleeding does not reliably exclude endometrial cancer.

DILEMMAS ABOUT THE SELECTION OF ANESTHESIA FOR ELECTIVE CESAREAN SECTION IN PREGNANT WOMEN WITH MYOTONIC DYSTROPHY TYPE 2 AND SUSPECTED von WILLEBRAND DISEASE: A CASE REPORT.

With advancement of medicine in the field of diagnostics and treatment of women suffering from certain genetic disorders, more and more women have attained reproductive age and desired fertility. Maintaining pregnancy, as well as bringing it to an end poses a real challenge not only for obstetricians, but also for anesthesiologists involved in the procedure. In our case report, we describe anesthetic management of a female patient suffering from myotonic dystrophy type 2 and suspected von Willebrand's disease, and undergoing elective cesarean section. It is acknowledged that both diseases have their own peculiarities and specificities related to anesthesia and require careful consideration when it comes to selecting it. Bearing in mind the advantages and disadvantages of certain types of anesthesia, we believe that in this case, general anesthesia was a better choice compared to the regional techniques of anesthesia.

A multidisciplinary approach to a patient with vulvodynia: a successful treatment and outcome.

Vulvodynia is chronic vulvar pain or a burning sensation lasting for at least 3 months without a cause. We present the case of a 53-year-old postmenopausal woman that experienced vulvar and vaginal burning, and discomfort and pain during sexual intercourse for 3 years, which greatly reduced her quality of life (QOL) despite the absence of itch and genital skin lesions. Her regular gynecological exams showed no pathology, and so she was referred to a dermatologist, who initiated a multidisciplinary treatment approach involving several specialists: an anesthesiologist, gynecologist, urologist, psychiatrist, and dermatologist. Targeted psychiatric treatment (amitriptyline), together with acupuncture treatments and support by a gynecologist, led to a major improvement in symptoms and QOL, as well as a decrease in depression and anxiety measured by the Beck Depression Inventory II (BDI-II) and State-Trait Anxiety Inventory (STAI). A multidisciplinary and integrative approach was crucial for determining a diagnosis and achieving an excellent outcome.

Sexuality in Assisted Reproductive Technology Couples.

BACKGROUND: Sexuality is a complex social and psychological phenomenon even more complicated in the setting of Assisted Reproductive Technology (ART). SUBJECTS AND METHODS: In total 192 participants entered the study (96 couples) in the process of ART. Participants filled up anonymous questionnaire while waiting routine procedure. At the time of questionnaire males and females were in separate rooms without knowledge about partners answers. RESULTS: The frequency of sexual intercourse was not related to the sociodemographic variables in women but was related to education level and work status. More educated men who were employed had more frequent sexual intercourses. Moreover, the frequency of the sexual intercourse was not related to the duration of the relationship nor the infertility treatment. The correlational analyses showed that the frequency of sexual masturbation was not related to the sociodemographic variables, except for place of living. Both women and men from more urban areas reported to engage in masturbation more often. The frequency of specific sexual activities did not differ between reports by women and men for vaginal, oral, anal, and foreplay activities. However, men reported engaging in masturbation more often than women. CONCLUSION: The frequency of sexual activities is similar in women and men for vaginal, oral, anal, and foreplay activities. However, men reported engaging in masturbation more often than women. ART could only slightly affect quality of sexual life. Both partners should be informed.

OBSTETRIC INJURY OF THE RECTUM WITH INTACT ANAL SPHINCTER - TWO CASE REPORTS.

Background: Injury of the rectum with intact anal sphincter is an extremely rare but very serious complication of vaginal delivery. It is also called a "buttonhole" tear. Case: We present two cases of "buttonhole" tear/injury. Results: In one case, the injury was recognized at the time of delivery and adequately treated. In the other case the injury was not diagnosed on time and the patient was treated for complications on the 6th postpartal day. Conclusion: The consequences for the wellbeing of young mothers with perineal injury can be serious and affect social and sexual aspects of their lives. Adequate surgical treatment and postoperative care assure optimal results and prevent long term complications such as fistulas or fecal incontinence.

RISK ASSESSMENT IN PREGNANCY AMONG WOMEN AGED OVER FORTY.

The objective of this study was to assess the relationship between women's age and risk of pregnancy-related complications. The study was a retrospective cohort analysis of the pregnancy-related complications and outcomes between two age groups of parturient women. Categorical data were expressed as absolute and relative frequencies. Statistical analysis was performed using χ2-test. The incidence of gestational diabetes was higher in the 40-47 age group as compared with the 20-24 age group. The rates of hypertension, preeclampsia, intrahepatic cholestasis of pregnancy and hypothyroidism did not differ between the two groups. The rates of labor induction, oxytocin use, vaginal delivery, and need for episiotomy were higher in younger age group. Dystocia and breech presentation as indications for cesarean section were more common among younger women. According to study results, the risk of gestational diabetes and rates of cesarean delivery increased with advanced maternal age.

URETERAL TRIPLICATION ACCIDENTALLY FOUND DURING CERVICAL CARCINOMA OPERATION.

Ureteral triplication is a very rare anomaly found in the upper urinary tract. This condition can be connected with a higher incidence of congenital anomalies and predisposition for urinary infections. Operative procedure is considered in cases where symptoms reduce the patient's quality of life. The type of surgical treatment depends on symptom manifestation. The risk of renal failure is usually a deciding factor, which can be found in conditions such as vesicoureteral reflux, obstruction, ureteral ectopy and recurrent infections. Simultaneous treatment of upper and lower urinary tract can be performed. We report a case of a 38-year-old female patient diagnosed with cervical carcinoma, where ureteral triplication was detected incidentally during a radical operative procedure.

UTERINE RUPTURE IN THIRD TRIMESTER OF PREGNANCY FOLLOWING CORNUAL RESECTION DUE TO ECTOPIC PREGNANCY.

Uterine rupture during pregnancy is a critical obstetric complication associated with maternal and fetal mortality and morbidity. The risk is increased in patients with a history of previous uterine surgery including cesarean section, myomectomy, salpingectomy, as well as uterine and placental anomalies and polyhydramnios. It can also occur spontaneously. We present a case of uterine rupture in the early third trimester in a woman who had undergone previous laparoscopic removal of the left fallopian tube due to sactosalpinx and laparotomic removal of left uterine horn due to ectopic pregnancy.

The Influence of Psychological Stress on HPV Infection Manifestations and Carcinogenesis.

Psychological stress is an important factor involved in disease manifestations of human papillomavirus (HPV) infection, and it can participate in HPV-associated carcinogenesis. The impact or effect which stress can have (exert) depends on a person's genetic pool, experiences and behaviors. Due to inconsistencies in some study results, this issue remains a subject of research. Concerning the course of HPV manifestations, it has been observed that a higher number of life stressors in at least the previous 6 months, the absence of social support and the types of personal coping mechanisms employed, all influence HPV progression. In women with cervical dysplasia, a connection between greater stress experiences and dysregulation of specific immune responses has been observed. Once HPV enters a cell via the α6 integrin there are three possible sequences: latent infection, subclinical infection, and clinically manifest disease. HPV proliferation in differentiated epithelial cells induces morphologically cytopathic changes (koilocytosis, epidermal thickening, hyperplasia, hyperkeratosis). Oncogenic transformation requires the integration of the virus genome into the host genome. In doing so, DNA in the E1 region of E2 breaks down, leading to transcription disorders of E6 and E7. For the formation of irreversible malignancy, the following sequence is necessary: initial expression of E6 and E7 genes followed by suppression of apoptosis and the stabile expression of E6 and E7 proteins that protect transformed cells from apoptosis. A successful immune response is characterized by a strong, local cell-mediated immune response. Several factors are important for the regression of HPV manifestation/infection, among which is psychological stress which can prolong the duration and severity of HPV disease. Stress hormones may reactivate latent tumor viruses, stimulate viral oncogene expression, and inhibit antiviral host responses. In the regression of HPV infection, increased activity of Th1 cells was observed. However, during psychosocial stress, a decrease in the Th1 type of immune response is seen, and there is a shift towards a Th2 response. Understanding perceived stress and biological changes in stress, as well as the evaluation of immune parameters, gives researchers a better picture of how stress influences HPV infections and how to improve disease management and outcomes.

Male to female birth ratios over a 35-year period.

Aim Along with changes to the human physique recorded over the past decades in certain countries, there are also changes concerning the male-female birth ratio. The aim of this study was to establish the movement of male-female birth ratios and factors affecting the ratio. Methods This retrospective study was conducted in Zagreb, Croatia, in the period from 1985 to 2019 on a sample of 3804 newborns. Results In the 35-year period the ratio of boys and girls at birth did not change significantly. Girls had lower birth weight, and boys had higher birth length. In the war period (1992-1994), a mild increase in the ratio of boys was noted, but not statistically significant. Father's age in the last period examined (2007-2009) showed to be a statistically significant predictor of the child's gender. Namely, the descendants of younger fathers were statistically significantly more frequently girls, while the descendants of older fathers were more frequently boys. Married mothers had higher percentage of male births (51.5%), and a lower percentage (47.1%) by unmarried mothers. Conclusion The changes in birth ratios are particularly pronounced in different age and socioeconomic groups of parents nowadays when the growth of living standards is accompanied by significant changes of the human physique.

Urinary troponin concentration as a marker of cardiac damage in pregnancies complicated with preeclampsia.

Pregnant women with preeclampsia experience significant hemodynamic changes which lead to an increased myocardial workload. In response to increased demands in pregnancy, the heart muscle responds with ventricular remodeling process which involves cardiac muscle hypertrophy. Opposed to occurrence of eccentric ventricular hypertrophy in normal pregnancy, myocardial remodeling in a form of concentric hypertrophy will occur in pregnant patients with preeclampsia. Increased myocardial workload is manifested by an increased troponin release. As process of troponin degradation continue, filtration of degradation fragment through glomerular membrane occur, raising the possibility of it's detection in urine. Degradation fragments of troponin molecules are estimated to be 20 kDa with preserved immunoreactivity to high-sensitivity assays. Some of the authors suggest that serum levels of cardiac troponin I might be elevated in patients with hypertension, as well as in preeclamptic pregnant women. It is to be expected that evaluation of severity of the myocardial damage in pregnant woman with preeclampsia may be performed by measuring levels of troponin in the urine using high-sensitivity assays. Designing of urine dipstick will help to detect an early phase of myocardial involvement in preeclamptic pregnancies.

Spontaneous Rupture of Venae Gastricae Breves in Pregnancy: Case Report.

INTRODUCTION: Hemiperitoneum caused by venous bleeding from the hilum of the spleen is a rare cause of acute abdomen in the last trimester of pregnancy. MATERIAL AND METHODS: We are presenting a case of a twenty-nine-year-old primipara with the clinical picture of acute abdomen. CASE REPORT: Primipara in the 36th week of pregnancy presented with the clinical picture of acute abdomen with the ultrasound finding of free fluid in the abdominal cavity and foetal bradycardia. Considering the clinical picture of the mother and the risks for the foetus, it was decided to complete the pregnancy with an emergency caesarean section. During the procedure, exploration of the abdominal cavity found the bleeding site from the venae gastricae breves, and a surgeon stopped active bleeding. CONCLUSION: Non-obstetric bleedings are not common in pregnancy, but they are life-threatening both to the mother and the foetus. The exact cause is usually found during the surgical procedure. If a pregnant woman presents with a clinical picture of abdominal pain, and the signs of foetal distress or clinical instability of the mother are also present, an emergency surgical procedure is indicated. In this case, the indication was foetal bradycardia, and the child was born alive by a caesarean section, while an extended surgical procedure saved the mother's life.

CLINICAL VALUE OF TRANSVAGINAL ULTRASONOGRAPHY IN COMPARISON TO HYSTEROSCOPY WITH HISTOPATHOLOGIC EXAMINATION IN DIAGNOSING ENDOMETRIAL ABNORMALITIES.

The aim of our retrospective study was to compare the performance of transvaginal sonography in relation to histologic diagnosis of samples obtained by hysteroscopy through analysis of data collected over 16 years. Data on suspected formation of endometrial polyp or submucosal fibroid found on ultrasound examination were extracted. The study included a total of 3679 women examined during the 2000-2015 period. All women underwent ultrasound examination preoperatively for better planning the type and scope of operation to be performed. The study included only women with samples for histopathologic analysis collected during the operation. Ultrasound diagnosis of polyps compared with histology showed 89.6% sensitivity and 39.1% specificity. For submucosal myomas, sensitivity was 69.2% and specificity 91.3%. In conclusion, ultrasound is not reliable method for definitive diagnosis but it is an excellent orientation method.

INCREASED OASIS INCIDENCE - INDICATOR OF THE QUALITY OF OBSTETRIC CARE?

In the era of new molecular, epigenetic and proteomic discoveries, birth canal injuries seem like outdated discussion. A vast increase in the incidence of obstetric anal sphincter injuries (OASIS) has been recorded in the last two decades despite advantages in modern medicine and new obstetric methods. This increase might be attributed to the new classification of perineal injury but also to the new imaging methods, including endoanal sonography, which earlier identifies injuries that previously were considered to be occult and actually underwent unrecognized, and which should have been recognized immediately postpartum. OASIS are third and fourth degree perineal injuries that occur during delivery. The reported incidence of OASIS varies from 0.1% to 10.9%. It is well known that third and fourth degree perineal injuries occur more often in primiparae, and in cases of macrosomic newborn, dorsoposterior position of fetal head and shoulder dystocia. The protective role of episiotomy is controversial. Birth canal injury during delivery can happen to any parturient woman. It is important for obstetricians to have this in mind at every delivery. Repercussions of OASIS are serious and can persist for life. They include emotional, psychological, social, physical and sexual disturbances. Therefore, it is very important to recognize the risk factors, diagnose the injury on time and treat it properly by a multidisciplinary team. Accordingly, it can be concluded that the increased incidence of OASIS is a result of better recognition of the risk factors, reduced rates of unrecognized sphincter injuries, adoption of the new classification and better postpartum imagining methods for detection of occult injuries.

Auricular acupuncture as effective pain relief after episiotomy: a randomized controlled pilot study.

PURPOSE: Previously, pain treatment following episiotomy has relied on non-steroid anti-inflammatory drugs as analgesics, whose use during breastfeeding remains controversial due of their transfer to the child. METHODS: This was a pilot randomized parallel single-center study aiming to evaluate the effects of auricular acupuncture on pain relief after episiotomy. The primary outcome was reduction of pain intensity using visual analogue scale (VAS) scores during the first three postpartum days. The patients were allocated to either of the groups by using a heads-tails binary result coin toss method and the allocation was not masked. The study was completed after including 60 healthy women that underwent mediolateral episiotomy performed during vaginal delivery, with 29 receiving acupuncture therapy and 31 not receiving acupuncture therapy for pain relief. Oral analgesic therapy was made available per request for all patients. RESULTS: This study showed that subjective experience of pain was significantly reduced in the acupuncture group on the second and third postpartum days (P = 0.004, P = 0.005, P = 0.22). There were no adverse effects of acupuncture noted. CONCLUSIONS: Our findings confirm that auricular acupuncture therapy may be a valuable adjunct to analgesic therapy in patients undergoing episiotomy during vaginal delivery. The results prompt a question whether our current 'best practice' may yet be improved.

PREGNANCY OUTCOME IN GESTATIONAL DIABETES COMPARED TO BODY MASS INDEX.

Gestational diabetes involves disorder of glucose metabolism first diagnosed in pregnancy. Obese women undoubtedly have more often complications in reproductive age, such as fertility difficulties, spontaneous and recurrent miscarriages, premature births, and various obstetric and surgical complications related to the course of pregnancy, delivery and puerperium. Children of obese pregnant women are more likely to develop obesity in childhood and adulthood. We analyzed the outcome of 51 pregnancies in obese pregnant women and 50 pregnant women with normal body mass index. All women in both groups were diagnosed with gestational diabetes by the IADPSG criteria. We analyzed gestational age at delivery and mode of delivery, gestational weight gain, presence of concomitant diagnosis of gestational or chronic hypertension, difference in birth weight, and prevalence of hypertrophic newborns. There was no significant difference in gestational age at pregnancy termination and in the mode of delivery. There was a significant difference in gestational weight gain, number of pregnant women with hypertension, neonatal birth weight and number of hypertrophic children. Based on the data presented, we conclude that obesity is an unfavorable factor for pregnancy outcome. It also influences birth weight and fetal hypertrophy, as well as gestational weight gain.

Subcutaneous Dirofilariasis in Female Pubic Region - Case Report.

BACKGROUND: Number of reported cases of human dirofilariasis in the last couple of decades has been increasing. Dogs are the main reservoir hosts, while various mosquito species represent/serve as vectors. Human infections are caused by two different parasites: Dirofilaria immitis and Dirofilaria repens. Dirofilaria repens is currently considered to be one of the most rapidly-spreading human and animal parasite species in Europe. Clinical features are characterised by subcutaneous or ocular lesions which can persist for months without any symptoms. The disease is considered to be endemic in Mediterranean countries, central Asia, Israel, and Sri Lanka with increased incidence in Central and East Europe. Apart from the local population, tourists are also susceptible to this disease. Export of domestic animals can transfer parasites between different countries. This disease is rare in Croatia. CASE PRESENTATION: We are presenting a case of a 58-year-old female patient with dirofilariasis of the genital region caused by Dirofilaria repens, confirmed with PCR and sequencing. CONCLUSION: From the clinician point of view, subcutaneous dirofilariasis should be considered as a differential diagnosis in cases of long-lasting subcutaneous swellings.