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.

Management of cervical dysplasia in patient with Müllerian anomaly: diagnostic and therapeutic challenges.

PURPOSE: The study aim was to report diagnostic and therapeutic challenges in treatment of a patient with cervical dysplasia and con- genital uterine anomaly. CASE REPORT: A 53-year-old women with Müllerian anomaly - uterus duplex (bicorporal septate uterus) and Y-shaped endocervical canal was referred due to repeated abnormal Pap smears. She underwent endocervical curettage of both canals and the endocervical septum biopsy which revealed presence of cervical intraepithelial neoplasia (CIN) III. Cervical conization was considered technically unfeasible because of abnormal cervical anatomy (lesions deep in the cervical canal on the cervical bifurcation where the cervical wall is the thickest). Classical open abdominal hysterectomy was performed. Patient had two almost equally-sized, symmetrical uterine bodies connected in the isthmico-cervical region, with normal left and obstructed right hemi-vagina. Postoperative histopathological findings confirmed that dysplasia was located in the region where two endocervical canals conjoined. CONCLUSION: Diagnostic and therapeutic approach to patients with uterine anomalies has to be individualized, based on anomaly type, patient's age, reproductive history, and patient's preferences.

The Role of Surgeons' Colposcopic Experience in Obtaining Adequate Samples by Large Loop Excision of the Transformation Zone in Women of Reproductive Age.

Introduction: There is insufficient reporting on the level of colposcopic training for the safe use of large loop excision of the transformation zone. The aim of this study was to perform a quality assessment of large loop excision of the transformation zone in women of reproductive age by evaluating the surgeons' colposcopic experience. Materials and Methods: A retrospective cohort study was performed on diagnostic or therapeutic large loop excision of the transformation zone. The following variables were analyzed: age, parity, indications for surgery, level of surgeon's colposcopic experience, definitive histological diagnosis, margin involvement, and the presence and type of artifacts interfering with the pathological interpretation. Patients were divided into three groups: group A - 75 patients treated by junior colposcopists; group B - 74 patients treated by experienced colposcopists, and group C - 117 patients treated by expert colposcopists. Results: Regarding the presence and diagnostic significance of the artifacts the groups were significantly different. Inadequate samples were the least frequent in group C. Artifacts precluding histological diagnosis were the most common in group A. The margins were predominantly inconclusive in group A. Conclusions: A high rate of artifacts is a disadvantage of the large loop excision of the transformation zone performed by surgeons less skilled for colposcopy. Although large loop excision of the transformation zone is considered to be a minor surgery, skills in colposcopy are an essential prerequisite for optimal results.

Pregnancy after heart surgery--challenges.

PURPOSE: Advances in cardiac surgery significantly improve life expectancy and quality of life of patients with congenital or acquired heart disease. MATERIALS AND METHODS: The present study included 146 pregnant women who had antenatal care and gave birth at the Institute of Gynecology and Obstetrics in an interval of ten years from 1994-2004. Patients were divided in four groups according to the type of heart surgery. Group I included four patients with surgically corrected coarctation of the aorta. Group II included 27 patients with correction of the ostial stenosis. Group III had 68 patients with correction of congenital heart diseases, and group IV had 47 patients with artificial heart valves. RESULTS: There was 4% of heart failure after delivery. The incidence of hemorrhagic complications during pregnancy was 2.7% and 4.1% after delivery. The incidence of thromboembolic complications after delivery was 6%. Four newborns died; one of hydrocephalus and three of hypoxic ischemic encephalopathy. Two patients died. CONCLUSION: Patients with artificial heart valves need an enhanced level of medical care during pregnancy and labor.

Asymptomatic isthmico-cervical uterine perforation with IUD - our experience and literature review.

PURPOSE: The study aim was to report an unusual case of a misplaced IUD in isthmico-cervical region causing partial uterine perforation and discuss literature data regarding such a condition. CASE REPORT: A 50-year-old women was referred to the present institution for IUD extraction. She was diagnosed with spontaneously misplaced IUD located in isthmico-cervical region of the uterus causing partial perforation. The time of dislocation was unknown, as she was completely asymptomatic for ten years after IUD application. More-over, she had no risk factors for device misplacement. The removal of IUD was uneventful. CONCLUSION: Isthmico-cervical misplacement of IUD, although rare, can occur at any time and can be asymptomatic. Thus, women with IUD should be annually checked-up in order to prevent possible IUD complications.

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.

Platelet count as a predictive factor of neonatal outcome in twin pregnancy with fetal demise.

PURPOSE: During the last decade, the rate of twin pregnancies has increased and reached 3% of all pregnancies. MATERIALS AND METHODS: This study enrolled 36 twin pregnancies that were followed and delivered at the Clinic for Gynecology and Obstetrics, Clinical Center of Serbia over a five-year period. RESULTS: The first group included 15 patients with a monochorionic twin pregnancy, and the second group consisted of 21 patients with a dichorionic twin pregnancy. The platelet count was significantly lower in patients with APGAR scores of more than 8, with an average of 185,000/ml, and in patients with a score of less than 4, the average count was 221,000/ml. The perinatal mortality rate of the surviving twin was 33% in the monochorionic group and 0.4% in the dichorionic group. CONCLUSION: An increase in the maternal platelet count can be used as a predictor for a negative neonatal outcome of the surviving twin.

Successful pregnancy after pulmonary embolism and heparin-induced thrombocytopenia--case report.

The authors present the case of a nulliparous 34-year-old patient. At the tenth week of gestation, she developed phlebothrombosis of veins of the right leg and massive pulmonary embolism. After thrombolytic and heparin therapy she developed rethrombosis and heparin-induced thrombocytopenia type II. Lepirudin was introduced in therapy and in the 12th week of gestation acenocumarol was added. After the 34th week, she received danaparoid sodium. After a week, by cesarean section, a healthy and mature female was delivered.

Ultrasound parameters and L/S ratio in prediction of perinatal outcome in term-growth restricted newborns.

AIM: The relation between biophysical profile (BPP), cerebroplacental (C/P) ratio, and lecithin/sphingomyelin (L/S) ratio as a predictor perinatal outcome in term intrauterine growth restricted (IUGR) neonates was evaluated. MATERIALS AND METHODS: A retrospective study of the perinatal outcome of 77 term monofetal pregnancies complicated with IUGR fetuses (< 10 percentile) who were terminated by cesarean section in 2010 was performed at the Institute of Gynecology and Obstetrics, Belgrade. RESULTS: The most frequent early neonatal complication was asphyxia. The authors found a strong correlation between the L/S ratio and birth weight (BW) r = 0.609, as well as between BPP and Apgar score 5 r = 0.583. Significant negative correlation was found between asphyxia and BPP r = -0.398, as well as between asphyxia and C/P ratio r = -0.379. CONCLUSION: In serous IUGR neonates, low values of BPP and L/S ratios predicted asphyxia.

Doppler examination in the evaluation of outcomes in pregnancies complicated by gestational hypertension and fetal intrauterine growth retardation--is it enough?

AIM: The relations between abnormal umbilical and cerebral Doppler, cerebral-umbilical (C/U) ratio, and outcomes in pregnancies complicated by gestational hypertension and fetal intrauterine growth retardation were evaluated. MATERIALS AND METHODS: A retrospective study of 53 monofetal pregnancies in 2010 was conducted at the Institute of Gynecology and Obstetrics, Belgrade. STATISTICAL ANALYSIS: chi-square likelihood ratio test, Student's t-test and Spearman's coefficient correlation. RESULTS: There was not a significant correlation between the timing of registration of abnormal umbilical Doppler to delivery and outcomes of high-risk pregnancies. There was a significant correlation between C/U ratio and APGAR-5 (p = 0.003). We found a significant correlation between neonatal birth weight and APGAR-5 (p = 0.000), neonatal asphyxia (p = 0.000), intracranial hemorrhage (p = 0.000) and respiratory distress syndrome (p = 0.000). CONCLUSION: Umbilical and cerebral artery Doppler is a relatively poor predictor of neonatal outcome. It seems that neonatal birth weight is the best predictor of neonatal outcome in high-risk pregnancies.

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.

Intramuscular fetal corticosteroid therapy short-term effect on maternal-fetal Doppler velocimetry.

AIM: The aim of the study was to assess the short-term effects of intramuscular (IM) corticosteroid therapy (CST) on fetoplacental and fetal circulation in high-risk pregnancies of preterm labor. METHOD: We evaluated the effect of IM fetal single-dose dexamethasone (4 mg/kg) on fetoplacental and fetal circulation two hours before and 0-4 hours after CST in 38 fetuses after the 32nd week of gestation. RESULT: Changes in the umbilical artery (UA) resistance index (RI) after fetal CST (AU RI1) were significantly correlated with gestational age after the 32nd week at recording r = 0.354; p < 0.05. There was a statistically significant difference of RI in the descending aorta (DAo) before and after therapy; p < 0.001 (-0.04-0.01), 95% confidence interval (CI) for differences. CONCLUSION: Short-time effects after fetal IM CST include an increased index resistance in DAO as well as decreased RI in UA after the 32nd week.