[Vaginal delivery versus cesarean section for term breech delivery].

BACKGROUND/AIM: The optimal method of delivery for breech presentation at term still remains a matter of controversy. This is probably due to the fact that the skills of vaginal breech delivery are being lost. The aim of this study was to examine risk factors: mother's age, parity, labor's duration, estimated neonatal birth weight for the mode of breech presentation delivery at term as well as the influence of the delivery mode on neonatal outcome. METHODS: A retrospective study of 401 terms (more than 37 week's gestation) breech deliveries at the Institute of Gynecology and Obstetrics, Belgrade, from 2007 to 2008 was made. The following groups with respect to mode of delivery were included: the group I - vaginal delivery (VD) in 139 patients; the group II - urgent cesarean section (UCS) in 128 patients; and the group III - elective cesarean section (ECS) in 134 patients. Mother's age, parity, duration of VD, neonatal birth weight (BW), the Apgar score at 5th minute, and duration of stay in a neonatal intensive care unit (NICU) were determined. Neonatal mortality and major neonatal morbidity were compared according to the route of delivery. Fetuses and neonates with hemolytic disease and fetal and neonatal anomalies were excluded from the study. For statistical analyses we performed Student's t test, Chi2 likelihood ratio, Kruskall-Wallis test, Mann Whitney test, and ANOVA. RESULTS: The mean age of patients in the group I was 28.29 +/- 4.97 years, in the group II 29.68 +/- 5.92 years and in the group III 30.06 +/- 5.41 years. Difference in mother's age between the group I and III was significant (p = 0.022). In the group III there were 73.9% nuliparous similarly to the group II (73.4%). We performed ECS in 54.6% of the nuliparous older than 35 years, and 54.4% multiparous younger than 35 years were delivered by VD. The use of oxytocin for stimulation of vaginal labor was not associated with its duration (p = 0.706). Lowset maneuver was performed in 88.5% of the VD. Mean BW of neonates was 3189.93 +/- 399.42 g in the VD group, 3218.59 +/- 517.71 g in the UCS and 3427.99 +/- 460.04 g in the ECS group. Neonates of the estimated BW below 2500 g were delivered by UCS in 5.5% cases, vaginally in 3.6% cases and by ECS in 2.2% cases. Neonates of the estimated BW above 3 500 g were delivered by ECS in 44.8% cases, vaginally in 23.0% cases and by UCS in 30.5% cases. There was a statistically significant difference between the VD and UCS groups (p = 0.004). Neonatal well-being was diagnosed in 75.5% of the neonates in the VD group, in 72.4% of the neonates in the ECS group, and in 65.5% of the neonates in the UCS group. The Apgar score at 5th min > 8 was observed in 96% of the neonates in the VD group, in 97.5% of the neonantes in the ECS group and in 94.5% of the neonates in the UCS group. In breech presentation, perinatal asphyxia remained increased in the VD group by 9.4% as compared with the UCS group, 5.5% (p = 0.001) and the ECS group, 3.0% (p = 0.016). Neonates stayed in NICU significantly longer after UCS compared with VD or ECS (7.21 +/- 10.74 days vs 3.99 +/- 1.33 days and 5.34 +/- 2.88 days, respectively; p = 0.001 and p = 0.037, respectively). There was no diagnosed intracranial hemorrhage, brachial plexus injury and birth trauma in any groups. Also, there was no early neonatal death. CONCLUSION: For breech presentation elective cesarean section remains the major delivery method in nuliparous older than 35 years, while vaginal delivery is considered to be the method of choice in younger multiparous with ultrasonographically estimated neonatal birth weight 2500-3500 grams.

[Histochemical and immunohistochemical analysis of ruptured atherosclerotic abdominal aortic aneurysm wall].

BACKGROUND/AIM: The main complication of the atherosclerotic abdominal aortic aneurysm (AAA) is her rupture that begins with lesion in intima and rupture. The purpose of this work was to determine immunocytochemical and morphofunctional characteristics of the cells in aortic wall in ruptured atherosclerotic abdominal aortic aneurysm. METHOD: During the course of this study, 20 samples of atherosclerotic AAA were analyzed, all of them obtained during authopsy. The samples were fixed in 4% formalin and embedded in paraffin. Sections of 5 microm thickness were stained histochemically (of Heidenhain azan stain and Periodic acid Schiff--PAS stain) and immunocytochemically using a DAKO LSAB+/HRP technique to identify alpha-smooth muscle actin (alpha-SMA), vimentin, myosin heavy chains (MHC), desmin, S-100 protein, CD45 and CD68 (DAKO specification). RESULTS: The results of our study showed that ruptured atherosclerotic AAA is characterized by a complete absence of endothelial cells, the disruption of basal membrane and internal elastic lamina, as well as a presence of the remains of hypocellular complicated atherosclerotic lesion in intima. On the plaque margins, as well as in the media, smooth muscle cells (SMCs) are present, which express a alpha-SMA and vimentin (but without MHC or desmin expression), as well as leukocyte infiltration, and a large number of foam cells. Some of the foam cells show a CD68- immunoreactivity, while the others show vimentin- and S-100 protein-immunoreactivity. Media is thinned out with a disorganized elastic lamellas, while adventitia is characterized by inflammatory inflitrate (infection). CONCLUSION: Rupture of aneurysm occurs from the primary intimal disruption, which spreads into thinned out media and adventitia. Rupture is caused by unstable atherom, hypocellularity, loss of contractile characteristics of smooth muscle cells in intima and media, neovascularization of the media, as well as by the activity of the macrophages in the lesion.

[Immunocytochemical characteristics of submucosal uterine myomas].

BACKGROUND/AIM: Myomas of the uterus, the most common benign tumors, have been studied for decades from the aspects of different basic and clinical disciplines. Despite this fact, their pathogenesis is still poorly understood. The aim of this study was to determine immunocytochemical characteristics of smooth muscle cells and connective tissue components of submucosal myomas of the uterus. METHOD: During the course of this study, 25 samples of submucosal myomas of the uterus were analyzed, all of them obtained during the surgery, after abdominal histerctomy by Aldridge. The samples were fixed in 4% formalin and embedded in paraffin. Sections of 5 microm thickness were stained immunocytochemically using the DAKO LSAB+/HRP technique to identify alpha-smooth muscle actin (alpha-SMA), vimentin, desmin, CD34, CD45, CD68 and PCNA (DAKO specification). RESULTS: Our results suggest that submucosal myomas of the uterus are build-up of smooth muscle cells which are immunoreactive to alpha-SMA and desmin, but also to a certain number of smooth muscle cells which are immunoreactive to alpha-SMA and vimentin. Some of vimentin-immunoreactive cells also show an immunoreactivity of PCNA. In the build-up of connective stroma CD34-immunoreactive fibroblasts and neovascular formations are also present. By examining the distribution of CD45 antigen, at all the analyzed samples we observed a weak reaction. CONCLUSION: Submucosal myomas of the uterus are made-up of smooth muscle cells of the highly differentiated contractile phenotype (alpha-SMA- and desmin-immunoreactivity), as well as smooth muscle cell of the synthetic phenotype which proliferate (alpha-SMA-, vimentin- and PCNA-immunoreactivity). In submucosal myoma of the uterus there is a significant presence of connective tissue as a result of synthetic activity of fibroblasts, which clearly differ in their immunocytochemical characteristics from smooth muscle cells of the synthetic phenotype.