Opportunities for, and barriers to, uterus-preserving surgical techniques for placenta accreta spectrum.

INTRODUCTION: Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual's preference, and the treating team's expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well-being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta in situ is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS-PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision-making. MATERIAL AND METHODS: Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered. RESULTS: A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman's wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%). CONCLUSIONS: Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.

Maternal Vaccination in Pregnancy: An Assessment of Influenza, Pertussis, and COVID-19 Vaccination Rates in Cracow, Poland.

BACKGROUND Maternal vaccination during pregnancy reduces the risk of severe course and complications from infections both for the mother and her child. As information regarding immunization status of pregnant women with recommended vaccines in Poland is scarce, this questionnaire-based study aimed to identify influenza, pertussis (whooping cough), and COVID-19 vaccination in 205 pregnant women in Cracow, Poland, between February and April 2023. Another objective was to assess whether any of the maternal factors might influence women's decision to inoculate during pregnancy. MATERIAL AND METHODS An anonymous and self-reported questionnaire developed specifically for this study was disseminated among postpartum women, who gave birth and were hospitalized at the Department of Obstetrics and Perinatology of the University Hospital in Cracow, Poland, between February and April 2023. Study participants were asked about their basic sociodemographic and obstetric data, as well as their immunization status regarding influenza, pertussis, and COVID-19 during their most recent pregnancy. RESULTS Only 12.2% and 23.4% of study participants received influenza and pertussis vaccinations, respectively, during pregnancy, while 61.5% of pregnant women reported vaccination with at least 2 doses of the mRNA COVID-19 vaccine. Features including type of occupation, place of residence, gravidity, and parity were statistically significant (P.

Analysis of intravaginal misoprostol 0.2 mg versus intracervical dinoprostone 0.5 mg doses for labor induction at term pregnancies.

OBJECTIVES: Labor-induction methods are used in about 23% of labors. Most commonly, pharmacological methods are used to pre-induct the labor with dinoprostone - a PGE2 analog, and misoprostol - a PGE1 analog. The aim of this study was to evaluate two pharmacological methods of labor induction with the use of prostaglandins applied via an intravagi-nal insert containing misoprostol at a dose of 0.2 mg and intracervical gel containing dinoprostone at a dose of 0.5 mg. MATERIAL AND METHODS: This retrospective study was conducted on a group of 50 adult patients qualified for the pre-induction of labor. Following data were recorded: the time from the drug administration to the beginning of regular contractile function, the time from administration to amniotic fluid rupture, the time from medicament administration to the vaginal labor or caesarean section, the duration of I, II and III stages of labor, the delivery method and in the event of caesarean section - the indications for surgery. RESULTS: In comparison to dinoprostone, the misoprostol application was found to shorten the time from drug administration to amniotic fluid rupture by 14.1 hours, the time to the beginning of the first stage of labor by 11.7 hours and from the drug administration to the delivery by 17.3 hours (p-value < 0.05). The duration of the first stage of labor in the misoprostol group was shorter by 1.2 hours than in dinoprostone group (p-value < 0.05). CONCLUSIONS: Application of intravaginal insert with misoprostol at a dose of 0.2 mg appears to be a more effective method of labor induction in comparison to intracervical gel with dinoprostone at a dose of 0.5mg. Thorough analysis of these methods requires further studies.

[The level of implementation of the prevention program of group B Streptococcal infection during pregnancy and in newborns in accordance to the recommendations of the Polish Gynaecological Society - questionnaire survey].

Background: Maternal colonization of Streptococcus agalactiae in pregnancy constitute an important clinical problem, that may result in serious consequences, especially for the newborn. Streptococcus agalactiae is a gram-positive beta-hemolytic streptococci belonging to the serological group B (GBS). According to recent data the GBS is found in 10-30% of healthy women, and the carriage of pathogen is usually asymptomatic. In order to minimize the risk of vertical transmission of the infection to the newborn during the labor, the Polish Society of Gynecology (PTG) has introduced the guidelines of GBS colonization screening for all pregnant women. Objectives: In this paper, the level of implementation of the screening tests in accordance to the recommendations of the PTG was evaluated. We also assessed the level of knowledge and awareness of pregnant women in detection of GBS colonization during the pregnancy and the prevention of infection in newborn. Material and method: The survey was conducted among the 172 women hospitalized in hospital maternity wards in the first days of postpartum. Results: Despite the introduction of the Polish Society of Gynecology guidelines, there are still cases of improper screening methods and medical interventions in the event of positive test results. Biological material was collected in 86% of patients (swabs from the genital tract, anus or urine culture). A positive result was found in 22% of patients. In 54% of patients swabs were taken at the recommended period of 35-37 weeks. The recommended collection of the material both from vagina and anus was taken only in 39% of patients. The majority of participated women described their knowledge of the risk associated with group B Streptococcal colonization as good, however only half of them found acquired information sufficient. Despite the implementation of guidelines Polish Gynaecological Society the incorrect conduct of the prevention against GBS is still performed in some cases. Conclusion: It is appropriate to perform consciousnessraising campaigns on screening of GBS among patients and doctors.

[The influence of tocolytic drugs usage in the third trimester of pregnancy on obstetric and neonatal outcomes]. / Wplyw stosowania Ieków zapobiegajacych porodowi przedwczesnemu w III trymestrze ciazy na wyniki poloznicze oraz neonatologiczne.

INTRODUCTION: The occurrence of preterm labor is the cause of 75% of preterm births. Prematurity is the leading cause of mortality of children under four weeks of age. Tocolytic drugs are used widely in the treatment of preterm labor. The aim of this study was to assess the impact of the tocolytic therapy on obstetric and neonatal outcomes. MATERIAL AND METHODS: The prospective, cohort study included 499 pregnant women The study enrolled women who met certain criteria of age, with singleton pregnancy, having no chronic diseases. After delivery the following data were obtained: sociodemographic profile (including data on occupational activity), body height and weight before pregnancy, weight gain, duration of pregnancy, mode of delivery, obstetric complications, medications, anthropometric parameters and state of health of newborns. A group of patients treated with tocolytic drugs and a control group were identified. Then obstetric and neonatal outcomes in both groups were subjected to statistical analysis. RESULTS: There was no statistically significant difference between the two groups in terms of the following variables: mother's age, her education, professional activity of mothers in the first and second trimester of pregnancy, weight gain during pregnancy, parity, exposure to passive smoking during pregnancy, method of pregnancy termination. We found a statistically significant difference between the groups with respect to maternal weight before pregnancy (lower in the group using tocolytics), the average duration of pregnancy (lower in the group using tocolytics), the frequency of preterm birth (higher in the group using tocolytics) and neonatal anthropometric parameters and the number of points in the Apgar score at 5 minutes of age (lower in the group using tocolytics). CONCLUSIONS: Low pregestational weight is a risk factor for preterm labor. Term birth rate in pregnant women treated for preterm labor is significantly smaller compared to the general population, which may indicate low efficacy of tocolytic drugs. There was no positive correlation found between the professional activity of pregnant women and the risk of threatening preterm labor.

Comparison of labor duration of induced labor with dinoprostone insert vs spontaneous labor.

OBJECTIVES: Labor induction is one of the most common procedures in modern obstetrics. One in five pregnant women and 30-40% of women delivering vaginally undergo this procedure. If the cervical status is unfavorable, a ripening process is used prior to induction to shorten the duration of oxytocin administration and maximize the possibility of vaginal birth. The aim of this study was to compare the duration of labor induced with dinoprostone vaginal insert to spontaneous labor. MATERIAL AND METHODS: It was a retrospective study conducted between May 2019 and February 2021 in the tertiary reference center, the Obstetrics and Perinatology Department of the Jagiellonian University Hospital in Krakow. The research group involved 182 patients in singleton pregnancy at term, qualified for cervical ripening procedure. The control group consisted of 178 patients that were delivering spontaneously and admitted to the delivery ward in the first stage of labor. Statistical analysis was performed to compare the duration of labor between groups. To find factors affecting the procedure we compared different models consisting of maternal and fetal characteristics. RESULTS: Successful vaginal delivery in the dinoprostone group was achieved in the group of 88% of patients. There was no significant difference in labor duration between the groups: 315 minutes in the study group and 300 min in the control group. Only being primipara was a factor related to longer labor in both groups. CONCLUSIONS: Pre-induction with dinoprostone insert and additional foley catheter, if indicated, does not make labor longer in comparison with spontaneous labor.

Cesarean section complicated with presumed massive pulmonary embolism and cardiac arrest treated with rescue thrombolytic therapy-two case reports.

BACKGROUND: Massive pulmonary embolus (PE), resulting in cardiac arrest during pregnancy and postpartum, is a rare but potentially catastrophic event. The most severe manifestation of massive PE is cardiovascular instability, including cardiogenic shock and cardiac arrest requiring intensive care unit (ICU) admissions. Up to 23% of high-risk PE pregnant and postpartum patients experience cardiac arrest. CASE DESCRIPTION: Case 1, a 34-year-old obese patient, with a twin pregnancy, had cesarean sections in the 24th week of pregnancy due to premature abruption of the placenta. Immediately after the birth, she experienced a sudden cardiac arrest. Treatment was initiated in line with antimicrobial lock solutions (ALS), heparine and alteplase was administered due to suspected massive pulmonary embolism. After 20 minutes from return of spontaneous circulation (ROSC), the uterine atony and severe hemorrhage occurred, and a postpartum hysterectomy was performed. The mother and two daughters are alive in 2021. Case 2, a 24-year-old obese patient had a cesarean section due to abruption of the placenta in the 28th week of pregnancy. Twelve hours after cesarean delivery, the patient's condition suddenly deteriorated. The patient reported dyspnea, chest pain, and presented cyanosis. The blood pressure was 66/30 mmHg, heart rate 130/min, tachypnea with a respiratory rate of 30/min, saturation 80% on air. High flow oxygen via face mask with reservoir (FiO2 0.85) and ephedrine 2×10 mg i.v. were administered. Due to suspected pulmonary embolism, a bolus of 5,000 IU of heparin was administered iv. Despite the implemented measures, cardiac arrest was confirmed with the initial rhythm of pulseless electrical activity (PEA) (sinus tachycardia 120/min). Treatment consistent with ALS was initiated. Due to the high probability of pulmonary embolism, a bolus of alteplase was administrated. ROSC was obtained 7 minutes later. Because of obstetric hemorrhage hysterectomy was performed. The mother and the baby are alive in 2022. CONCLUSIONS: In light of current evidence, presented data suggest that early and aggressive recombinant thrombolytic use in case of cardiac arrest and suspected PE in obstetric patients may be life-saving, effective treatment with a good neurological outcome. Major bleeding complications should be anticipated when administering this therapy.

SARS-CoV-2 infection during pregnancy - single-center retrospective study.

OBJECTIVES: The SARS-CoV-2 virus infection has spread to almost all countries in the last two years. Pregnancy complicated with COVID-19 is a unique situation and challenge for doctors. The study aimed to evaluate obstetric results, and biochemical test results and to analyze the treatment used in pregnant patients complicated with COVID-19 infection. MATERIAL AND METHODS: A retrospective analysis of 146 pregnant patients hospitalized at the Department of Obstetrics and Perinatology Jagiellonian University Medical College (JUMC) in Krakow was conducted from July 2020 to August 2021. RESULTS: In the analyzed group respiratory failure occurred in 19.19% of cases and intravascular coagulation syndrome (DIC) in 1.37%. One patient died (0.68%). 16.6% of cases were transferred to the Intensive Care Unit (ICU) and required intubation. The remaining cases were mild: 39.04% were asymptomatic, 41.78% reported cough, 30.82% dyspnoea and 23.97% myalgia. In the laboratory tests increased values of CRP and IL-6 were observed with normal levels of leukocytes. Additionally, a decreased level of total protein and an increased level of d-dimers were detected. 98.63% of patients received a prophylactic dose of low molecular weight heparin. 46.58% of cases needed additional antibiotic therapy. Cesarean sections were performed in 59.59% of cases. The children were born in good general condition. Vertical transmission of SARS-CoV-2 to the newborn has not been confirmed. CONCLUSIONS: Data from the above study show a significant effect of COVID-19 on pregnant patients. Almost one in five pregnant women occurred respiratory failure and most of them had to be transferred to the ICU department and had to be intubated.

Influence of gestational diabetes mellitus on outcomes of preinduced labour with dinoprostone vaginal insert.

OBJECTIVES: The aim of this study was to evaluate the effectiveness of labour preinduction using a dinoprostone vaginal insert in patients with gestational diabetes mellitus versus patients undergoing labour induction for other causes. The second aim of the study was to compare perinatal outcomes in both groups. MATERIAL AND METHODS: The study has a retrospective character, conducted in 2019-2021 in a tertiary reference hospital. The following endpoints were assumed for the analysis: natural childbirth, birth occurring within 12 hours of dinoprostone administration and neonatal outcomes. Furthermore, indications of a Caesarean section were analysed. RESULTS: The percentage of natural childbirths was similar in both groups. Furthermore, in both groups, over 80% of patients gave birth within less than 12 hours following dinoprostone administration. Neonatal outcomes (body weight, Apgar score) did not differ statistically. Analysing indications for a Caesarean section, failure in the progress of labour was an indication in 39.5% of cases in the control group, 29.4% of cases in gestational diabetes mellitus (GDM), and 50% of cases in diabetes mellitus (DM). The risk of foetal asphyxia was an indication in 55.8% of cases in the control group, 35.3% of cases in GDM and 50% of cases in DM. Ineffective labour induction - no induction of the contractile function was an indication for a C-section in 4.7% of cases in the control group and 35.3% of cases in GDM; no cases were noted in DM (p = 0.024). CONCLUSIONS: The study demonstrated that patients undergoing labour induction due to GDM using a dinoprostone vaginal insert did not differ in terms of labour duration, oxytocin administration compared to patients undergoing labour induction for other causes. Furthermore, the same rate of Caesarean sections was found in the study group; however, these groups differ in terms of indications, including risk of foetal asphyxia (35.3% vs 55.8%), failure in the progress of labour (29.4% vs 39.5%), and no active labour (1.8% vs 1.5%). The neonatal Apgar score at 1.5 and 10 minutes after birth was similar in both groups.

ICTP concentration in cervical-vaginal fluid as a potential marker of membrane collagen degradation before labor.

OBJECTIVES: Numerous physical and chemical processes lead to rupture of membranes. Within the fetal membranes there are numerous types of metalloproteinases, which cause collagen type I degradation. The C-terminal telopeptide of colagen type I (ICTP) is the breakdown product of type I collagen. The aim of the study was to determine whether ICTP is secreted into the vaginal-cervical fluid (VCF) in the case of physiological rupture of the membranes of the fetus before delivery. MATERIAL AND METHODS: The study was conducted in March 2021 at the Department of Obstetrics and Perinatology of the Jagiellonian University in Cracow, Poland. Twenty-three cases were included in the study. During routine gynecological examination with the use of specula, VCF was collected twice in a volume of 50 µL. The obtained material was then subjected to enzyme immunoassay using the Human C-telopeptide of type I collagen (ICTP) ELISA Kit (Catalog Number. CSB-E10363h). The concentration of ICTP in the sample was calibrated. The concentration range that the device can detect was 25 ng /mL-800 ng/mL. RESULTS: The presence of ICTP in the VCF was confirmed. The minimum concentration was 43.72 ng/mL, the maximum was 762.59, in five cases the concentration was outside the maximum scale of the device. CONCLUSIONS: ICTP was confirmed in the VCF of pregnant women before physiological delivery. Further studies are required to accurately evaluate ICTP as a marker of the processes of collagen degradation in fetal membranes in the mechanism of physiological labor and premature rupture of the membranes.

COVID-19 Infection Complicated by Disseminated Intravascular Coagulation during Pregnancy-Two Cases Report.

Coagulopathies are one of the obstetric complications affecting the period of pregnancy, childbirth, and puerperium. One of the more severe and complex disorders of the haemostatic system is the disseminated intravascular coagulation syndrome (DIC), in which generalised activation of the coagulation system and activation of inflammatory cells occurs. DIC syndrome was observed in patients whose pregnancy was complicated by SARS-CoV-2 infection. Both the course of these cases and literature review indicate that particular notice should be paid to laboratory parameters of the coagulation system, closely monitoring the well-being of the foetus and, in the situation of acute DIC development, it is advised to deliver a baby and initiate intensive therapy.

[Bacterial vaginosis and preterm delivery risk]. / Bakteryjna choroba pochwy a ryzyko zagrozenia porodem przedwczesnym.

The aim of the study was to evaluate the impact of early, second trimester bacterial vaginosis [BV] on the number of threatened preterm deliveries. Group A consisted of 52 pregnant women in whom BV was diagnosed in the beginning of the 2nd trimester of pregnancy. Group A patients were treated with a 10 day course of metronidazole 0.5 g vaginally daily. Group B consisted of 122 pregnant women without BV. The number of cases with threatened preterm delivery was prospectively assessed in both groups. There were 28 cases of threatened preterm delivery in group A (53.8%) and 6 similar cases in group B (4.9%) (p < 0.05--Chi square test d.f.1). All cases (n = 20) of BV at the time of hospitalization due to threatened preterm delivery occurred in group A. The cases of threatened preterm delivery occurred significantly more frequently in pregnant patients who had the BV diagnosed in the beginning of the 2nd trimester. This may suggest the link between BV and the occurrence of threatened preterm deliveries.

Doppler velocimetry of the materno-fetal circulation in preterm delivered pregnancies complicated with hypertension.

BACKGROUND: Hypertension is one of the most frequent complications of pregnancy. Due to high risk of morbidity and mortality in both mothers and children, it is necessary to continuously monitor the pregnancy, principally with biophysical methods. Particularly, doppler velocimetry of the materno-fetal circulation proves useful. THE AIM of the study was to assess the usefulness of doppler test in monitoring the condition of the foetus in preterm delivered pregnancy complicated with hypertension. MATERIAL AND METHODS: The retrospective analysis comprised the data of 116 women who delivered prematurely at the Clinics of the Department of Gynaecology and Obstetrics at the Collegium Medicum of the Jagiellonian University in the years 2006-2007, resulting in creation of Group I involving 38 pregnant women with preeclampsia, and Group II of 36 women whose pregnancy was complicated with gestational hypertension. Control group was formed of 42 women with correct arterial blood pressure. When describing the groups, the differences in the birth weight and Apgar score were indicated. RESULTS: A significant statistical difference was found in the area of pulsation rate in the umbilical artery and cerebro-placental ratio (CPR). In the case of preterm delivery complicated with arterial pressure disorders, the foetus is characterised with worse organic perfusion and slower somatic growth than if no concomitant hypertension is present. Hypertension forms an additional risk factor in the course of preterm delivery, and doppler velocimetry is a good method for monitoring the condition of the foetus, as it allows for detection of irregularities and for implementation of relevant treatment to improve the newborn's condition at birth.

Low-Grade Metabolically-Induced Inflammation Mediators Interleukin-6, Adiponectin, and TNF-α Serum Levels in Obese Pregnant Patients in the Perinatal Period.

BACKGROUND Obesity is a major clinical problem. The number of obese pregnant women is rising rapidly. The consequences of obesity are significant and affect every aspect of perinatal care for both the mother and the developing fetus. Adipose tissue may be responsible for chronic subclinical inflammation in obesity, being a source of inflammatory mediators. The study was designed to evaluate the analysis of the serum concentration of inflammatory mediators, including interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and adiponectin, in obese pregnant women at full-term pregnancies. MATERIAL AND METHODS The study included 40 women with body mass index (BMI) less than 30 and 24 pregnant women with BMI equal to or greater than 30, admitted to the Perinatology and Obstetrics Department of the University Hospital in Cracow in the first stage of labor. Blood samples were taken from patients to detect the serum concentration of cytokines. Ultrasound was used to evaluate the development of the fetus, including estimated fetal weight, Doppler flows, and the amount of amniotic fluid. We also included the history of chronic diseases and other complications of the pregnancy. A p-value <0.05 was considered significant. RESULTS The level of adiponectin in obese patients as compared to controls was significantly lower. There was no statistically significant difference in either group when TNF-α and IL-6 were measured. The results of the survey are consistent with previous reports. CONCLUSIONS The exact role of inflammation in pregnancy is not well understood. Determining the exact functions of the different cytokines in physiological pregnancy and pregnancy complicated by obesity requires further study.

C-reactive protein as a predictor of threatening preterm delivery.

OBJECTIVES: Preterm deliveries represent still one of the most important problems in contemporary obstetrics. They are associated with prematurity and higher rate of perinatal mortality and morbidity. During the last few years, the role of C-reactive protein (CRP) in prediction of threatening preterm delivery was emphasized. CRP is produced mainly inside the liver as a response to acute and chronic inflammatory processes. AIM: The aim of this study was to assess relations between C-reactive protein, oxytocinase, izooxytocinase and vaginal culture in prediction of preterm delivery. METHODS: This study was performed in the years 2000-2004 in the Department of Septic Obstetrics and Gynecology of Collegium Medicum of the Jagiellonian University. Some 389 patients hospitalized because of threatening preterm delivery or preterm delivery in tractu were enrolled into the trial. CONCLUSION: C-reactive protein is a useful marker of threatening preterm delivery, overtaking the results of vaginal culture. CAP1 and CAP2 are effective biochemical markers in pregnancy monitoring.