Intrafetal laser ablation for embryo reduction from dichorionic triplets to dichorionic twins.

OBJECTIVE: To report the outcome of dichorionic (DC) triplet pregnancies reduced to DC twins by laser ablation of the pelvic vessels of one of the monochorionic (MC) twins. METHODS: Intrafetal laser embryo reduction (ER) from DC triplets to DC twins was carried out in 61 pregnancies at 11 + 0 to 14 + 3 weeks' gestation. Pregnancy outcome was examined. RESULTS: Intrafetal laser was successfully carried out in all cases, but ultrasound examination within 2 weeks of the procedure demonstrated that the MC cotwin had died in 28 (45.9%) cases and was alive in the other 33 (54.1%). In the DC group, there was one miscarriage at 23 weeks, one neonatal death after delivery at 26 weeks and in the other 31 cases there were two live births at a median gestational age of 35.3 (range, 30.4-38.4) weeks. In the 28 cases in which both MC fetuses died, there was one miscarriage at 16 weeks and in the other 27 cases the separate triplet was liveborn at a median gestation of 38.2 (range, 32.2-42.1) weeks. The overall rate of miscarriage was 3.3% (2/61) and that of preterm birth (PTB) at < 33 weeks was 6.8% (4/59). CONCLUSIONS: In the management of DC triplet pregnancies, ER to DC twins by intrafetal laser ablation is associated with lower rates of miscarriage or early PTB, compared with expectant management or ER by fetal intracardiac injection of potassium chloride. However, about half of the pregnancies result in the birth of one rather than two babies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[CLINICAL IMPLEMENTATION OF CELL-FREE DNA ANALYSIS IN MATERNAL BLOOD IN SCREENING FOR ANEUPLOIDIES IN SINGLETON PREGNANCIES].

OBJECTIVE: Clinical implementation of cell free(cf) DNA testing in maternal blood for aneuploidies in singleton pregnancies. METHODS: This is a retrospective study conducted in two centers for fetal medicine in Sofia, Bulgaria, between October 2013 and August 2015. We examined the clinical implementation of cf DNA testing in the routine practice for trisomies 21, 18 and13 after the performance of the first trimester combined test, second trimester biochemical test and/or the combination between first and second trimester integrated test. RESULTS: Cell-free DNA testing was performed in 170 singleton pregnancies with a median maternal age of 35 (range 22-46) years. The primary risk assessment for aneuploidies was derived from 95 cases after the first trimester combined screening test, 39 cases after the second trimester biochemical screening test, 16 cases after the integrated screening test and 20 cases there were no screening test performed. The results from the first line screening test were : 8 pregnancies with risk for trisomy 21 > 1: 100; 23 pregnancies with risk for trisomy 21 from 1:100 to 1: 300; 43 pregnancies with risk for trisomy 21 from 1:300 to 1:1000 and 76 pregnancies with risk for trisomy 21 < 1: 1000. No pregnancies with high risk for T13/T18 were identified. The analysis of cf DNA in the maternal blood reported 3 cases with T21 and no cases with T18 or T13. There was only one case of T21 in the group with risk >1:100 identified by the cf DNA analysis which was also identified by the first trimester combined screening test. The positive results were confirmed with invasive testing: CVS in the first trimester (one case) and Amniocentesis in the second trimester (two cases). CONCLUSION: Clinical implementation of cell-free DNA analysis in the contingent policy for screening could improve the detection rate for T21 and could reduce the rate of invasive procedures.

[FETAL THERAPY: INTRAUTERINE THORACO-AMNIOTIC SHUNTING IN MACROCYSTIC TYPE CYSTIC ADENOMATOID MALFORMATION OF THE LUNG: REVIEW OF THE LITERATURE AND CASE REPORT].

ABSTRACT OBJECTIVE: To present a case of macrocystic type cystic adenomatoid malformation of the lung (CCAM) treated with thoraco-amniotic shunt and to review the published data to evaluate the efficiency of thoraco-amniotic shunts for drainage of (CCAM). MATERIALS AND METHODS: This wass case reported of a fetus with a large thoracic cyst, major mediastinal shift and polyhidramnion treated with thoraco-amniotic shunting. We identified 8 cases diagnosed with CCAM and only one case met the criteria for fetal surgery. Thoracoamniotic shunting was successfully performed under local anesthesia and ultrasound control with operating time of 35 minutes. Medline was searched to identify cases of CCAM treated by thoraco-amniotic shunting. RESULTS: Fetal therapy forlung lesion was successfully performed at 30 weeks of gestation with CCAM volume ratio > 1.6 January, 2015 and amniodrenage after the procedure was carried out. The pregnancy has progressed uneventfully and planned Cesarean section was performed at 38 weeks of gestation. The optimal management of such case was performed for the first time in Bulgaria, which required an experienced interdisciplinary team. The newborn underwent resection of the lesion with no growth or neurodevelopment delay. The literature search identified cases with CCAM treated with thoraco-amniotic shunting between 1987 and 2016 and the the survival rate of non-hydropic fetuses that underwent treatment was 88%. CONCLUSIONS: Thoraco-amniotic shunting for macrocystic type CCAM is associated reduced risk of fetal intrauterine death and is also likely to be beneficial for the following major postnatal surgery

[LAPAROSCOPIC TREATMENT OF PRIMARY ABDOMINAL PREGNANCY: A CASE REPORT AND REVIEW OF THE LITERATURE].

Abdominal pregnancies are 1.4% of all ectopic pregnancies. They are mostly complicated and usually managed by laparotomy, but laparoscopy is an alternative method which some surgeons perform instead of laparotomy, especially in early pregnancy. We reported a 29 year old woman with supra pubic pain and vaginal bleeding. After sonographic evaluations, ectopic pregnancy was diagnosed and the patient underwent laparoscopic surgery for termination of pregnancy. Laparoscopy is a successful alternative method of surgery for abdominal pregnancies in first trimester.

[Ultrasound Examination and Management of Twin Pregnancy.]

Twin pregnancies are found in about 3 % of all pregnancies and 2/3 are dizygotic and 1/3 are monozygotic. In the last 30 years after the introduction of assisted conception and increasing maternal age the rate of twin pregnancies dramatically increased. Compared to singletons, twins have more complications such as intrauterine demise, intrauterine selective fetal growth reStriction, congenital anomalies, miscarriage and preterm labour. Monochorionic twins are at high risk for unique complications because of blood exchange through vascular communications in the shared placenta. Twin pregnancies should be considered as a high risk pregnancies and the well-being of the two fetuses should be taken into account with a strict protocol for follow up and management options. CONCLUSION: Ultrasound examination olavs a maior role in fetal surveillance.

[Intrauterine Fetal Growth Restriction- Screening Model. Literature Review.]

Placental dysfunction is involved in a spectrum of obs.tetric conditions including preeclampsia, placental abrution and intrauterine fetal growth restriction. Their timely and accurate recognition is often a chalange since diagnostic criteria are dill based on nonspecific signs and symptomes. Fetal growth restriction (FGR) refers to a fetus that has failed to achieve its genetically determined growth potential and affects up to 5-10% of pregnancies. FRR is associated with an increase in perinatal mortality and morbidity. The diagnoslic challenge is in distinguishing SGA pregnancies from FGR pregnancies because the majority of SGA pregnancies are associated with a good prognosis compared to FGR pregnancies. Multifetal gegations have a high incidence of FGR. About 20-30% of dichorionic twins will suffer from FGR, as will 40% of monochorionic twins. Ultrasound is the benchmark for accurate pregnancy dating and diagnosis of FGR. However, there is room for error and FGR is undetected in about 30% of routinely scanned cases and incorrectly detected in 50% of cases. In recent years, the main priority of the leading obstetric clinics in Europe and the USA is drafting a universal screening model for selecting patients at high risk of developing placental dysfunction. Now, this model is part of the standard screening for chromosomal aneuploidies in the firs and second trimester of pregnancy and prolonged screening in the second and third trimester in patients at high risk.

[SECOND STAGE IN MINIINVASIVE FETAL SURGERY FOR SEVERE CONGENITAL DIAPHRAGMATIC HERNIA. CASE REPORT].

We present a case of miniinvasive fetal surgery for CDH treated at 28 and 34 weeks of gestation. The first step was successfully performed at 28 weeks with Fetal Endoscopic Tracheal Occlusion with ballon. The second step was performed at 34 weeks for balloon removal. The necessity of fetal cytogenetic assessment and array CGH was carried out to exclude gene disorders that could lead to poor long-term outcome. A planned SC and optimal neonatology management were followed by a surgical operation of the newborn. Experienced interdisciplinary team successfully provide a perinatal and postnatal surgery for severe CDH. The newborn was discharged from the hospital 3 weeks after the repairing operation in a good condition.

[Prenatal diagnosis and fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia. Case report].

We present a case of severe isolated congenital diaphragmatic hernia (CDH) diagnosed at 19 weeks of gestation and treated at 28 weeks with Fetal Endoscopic Tracheal Occlusion (FETO). The CDH was left-sided with part of the liver in the thorax and lung area to head circumference ratio (LHR) of 0.9. The FETO was successfully performed under spinal anesthesia. The pregnancy is progressing uneventfully and ultrasound examination 10 days after the FETO demonstrated an increased LHR to 1.1. Treatment with FETO for severe CDH has been performed for the first time in Bulgaria and this procedure addressed several questions for optimal management by an experienced interdisciplinary team.

[New screening method for aneuploidies based on analysis of cell-free DNA in the maternal blood].

UNLABELLED: The national program of screening for aneuploidies in Bulgaria is based on first trimester combined test, second trimester biochemical test and/or the combination between first and second trimester integrated test. OBJECTIVE: To review the literature for studies analyzing cell-free (cf) DNA in the maternal blood and to report the clinical implementation and validation of the method in the clinical practice. Literature search and study selection extracted studies since 2011 when the first article was published. The data source included searches from PubMed and Medline. The reported results for detection rates (DR) and false positive rates (FPR) in singleton pregnancies were about 99.0% and 0.08% respectively, for trisomy 21, 96.8% and 0.15% for trisomy 18, 92.1% and 0.20% for trisomy 13, 88.6% and 0.12% for monosomy X. For twin pregnancies, the DR was 94.4% and FPR was 0% for trisomy 21. CONCLUSION: Analysis of cell-free DNA in the maternal blood is an effective method of screening for aneuploidies.

[THE VALUE OF COLPOSCOPY EXAMINATION IN DIAGNOSIS OF PRECANCEROUS AND CANCEROUS DISEASES OF THE CERVIX].

The aim of this study is to present the value of colposcopy examination in diagnosis of precancerous and cancerous diseases of the cenvix. A retrospective study analyze 127 patients at SA GBAL" Dr. Shterev Hospital" that undenNent, firstly cervical smear test and secondly a colposcopic punch biopsy The patients are divided in two groups--one group of cytologically non-signaled patients with results from the Pap test I-II and one group with cytologically -signaled patients with results from the Pap test III-IV The data shows a correlation between the cytological and histological results of the second group and absence of such a correlation in the first group. In the non-signaled group the mild precancerous lesions to Thvasive cen'ical cancer were left undiagnosed. The conduct of a routine colposcopy during preventive gynecological examination will reduce the deficiencies of the cytological method and by amplifying it, it will lead to better results of the diagnosis and treatment of the precanceroses and the cervical cancer.

[INTRODUCTION OF ENDOSCOPIC LASER THERAPY FOR COMPLICATED MONOCHORIONIC TWINS IN BULGARIA].

OBJECTIVE: The aim of this study is to describe our initial experience of endoscopic laser coagulation of inter-twin placental vessels in the treatment for severe twin-to-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) at SABBAL "Dr Shterev Hospiat". METHODS: Endoscopic laser surgery was carried out in eight cases of TTTS and two cases of sFGR at a median gestational age of 21.4 (range 16.4-23.1) weeks. In the group of TTTS there was one, three and four cases of Quintero stage 2, 3 and 4, respectively. Both cases of sFGR were Gratacos type 2. RESULTS: In the eight cases of TTTS, there was survival of both twins in four cases (one, two and one of Quintero stages 2, 3 and 4, respectively), survival of one twin in one case (Quintero stage 3) and death of both twins in three cases (all Quintero stage 4). In the sFGR group, both twins survived in one case and one survived in one case. The three cases of TTTS with death of both twins were in the first four cases of the series and the death occurred during or within 24 hours of the procedure where in 2 cases there was SROM with cervical length 7 and 12 mm respectively. In the seven cases with survivors, the median gestational age at delivery was 32.3 (range 28.1-37.0) weeks. CONCLUSIONS: Our results from endoscopic surgery in TTTS and sFGR are encouraging and are likely to improve with increasing experience. There was at least one survivor in two of the first four cases and in all six subsequent cases.

[THE GESTATIONAL DIABETES MELLITUS AS A SPECIFIC PREGNANCY STATE].

Pregnancy is a condition which result in a significant changes in the course of the metabolic processes in woman's body. The impairments in the carbohydrate metabolism, in particular Gestational Diabetes mellitus are the most frequent observed during pregnancy. Extremely important for the clinician is to knows the risk factors, which can predispose to the appearance of these disorders, and in time to explores the patients. This allows to avoid both early and late complications for the mother and her future child.

[Microbiological efficacy of a one-day treatment with triazole antimycotic I traconazole in mycotic colpitis].

INTRODUCTION: Fungal colpitis is the most common inflammatory disease of the vagina, whose proportion in the different groups of the patients ranges from 30% to 60%. The major cause is genus Candida. In 80% to 95% of the cases the reason is Candida albicans species and in 10% to 20%--the representatives of the species Candida Non-albicans. One problem that arises in this genital infection is the insufficient effectiveness of the drug treatment in many of the cases. MATERIALS, METHODS AND RESULTS: This study is a prospective and monitors 40 non-pregnant women, accounting therapeutic effect of Itraconazol in fungal colpitis. Patients had administered treatment with Itraconazol 2 x 200 mg/1 day, per oral. Microbiological testing was performed prior to the treatment and 2 to 4 weeks after completion of the therapy. We found C. albicans in 75% of the cases and in 25%--C. non-albicans (C. glabrata, C. kefyr, C. krusei, C. famata). In the group of C. albicans, good therapeutic efficiency was observed in 93.3% of the cases, while in patients with C. non-albicans it was in 80% of the cases. CONCLUSION: Itraconazol showed sufficiently high therapeutic effect for patients with fungal colpitis, it proved to be suitable for patients with Candida albicans and also in the cases with Candida non-albicans.

[Prenatal diagnosis and treatment of twin-to-twin transfusion syndrome].

UNLABELLED: Monochorionic twins originate of single placenta serving two twins, which potentionally could lead to unique complications including twin-to-twin transfusion syndrome, twin anemia--polycythemia sequence (TAPS), selective intrauterine growth restriction or twin reversed arterial perfusion sequence (TRAP). A shared placenta and fetoplacental circulation are responsible for significant discordance in amniotic fluid, fetoplacental hemodynamics, fetal size or fetal structural defects. All these complications pose high risk of fetal demise in one of the twins and therefore this could trigger death or neurological injury of the co-twin. The most severe complication of the monochorionic placenation is twin-to-twin transfusion syndrome. CONCLUSION: Prenatal management of complicated monochorionic twin pregnancy with twin-to-twin transfusion syndrome exposed to the risk of losing one or two twins in utero justifies the endoscopic laser coagulation for placental anastomoses as a first line treatment.

Characterization of clonogenic stromal cells isolated from human endometrium.

Human endometrium is an object of extensive restructuring and remodeling during the female reproductive life and it is quite tempting to assume that these periodic changes happen with the participation of cells that should have the basic characteristics of multipotent cells. The aim of this study was to search for the presence of cells with plastic adherence, clonogenicity, and differentiation in human endometrium. To this end, human endometrial stromal cells were cultured in vitro for more than 15 passages. Flow cytometry analysis of the cultured cells showed that they were positive for CD29, CD73 and CD90, which are considered to be the markers of cells with mesenchymal origin. The cells were negative for the hematopoietic cell markers (CD45, CD34, CD14, CD3, CD19, CD16/56, and HLA-DR). Further, it was shown that the cultured cells had 15% clonogenic efficiency and could be induced to differentiate into adipogenic cells containing typical lipid-rich vacuoles. These results demonstrate that the human endometrium contains a low number of cells with the characteristics of endometrial stromal stem/progenitor cells, which seem to belong to the family of the mesenchymal stem cells. It can be speculated that these cells are engaged into the monthly restructuring and remodeling of human endometrium.

[Assesment of the woman's age as a main predictive factor of assisted reproductive technology treatment outcome].

Several factors could be used as a predictors of in vitro fertilization treatment outcome: female age, aetiology of sterility, previous ovarian surgery, embryo morphology and cleavage rates and also the technique of embryo transfer. The aim of the present study is to evaluate the role of the age to be used as a prognostic factor for the sterility treatment outcome. The tasks we assigned were to compare the several parameters: duration of the stimulation, number of retrieved oocytes, fertilization rate, implantation rate and clinical pregnancy rate after IVF/ICSI in different age's groups. The study results clearly demonstrate that in spite of decreasing number of retrieved oocytes after the age of 30, the fertilization rate remains elevated till 40 years. Regardless of this fact, the implantation rate and the clinical pregnancy rate were significantly lower after the age of 35. Reduction of the success rate in these cases showed that ART, despite of its renewals, is not the strategy for getting over the age in human reproduction.

[Acromegaly and pregnancy]. / Akromegaliia i bremennost.

Pregnancy in women with acromegaly is very rare. The introduction of dopaminergic treatment revealed new possibilities for conception. Four acromegalic women who conceived during a course of bromcryptin treatment and after an unsuccessful transsphenoidal adenectomy are presented. Two of the women have given birth to a normal child, the third woman aborted willfully and the delivery of the fourth woman is forthcoming. Bromcyptin was given during the whole course of pregnancy in progressively increasing doses up to 15 mg daily according to the increased levels of the somatotrophic hormone (STH). The action of bromcryptin on some hormones of the mother and the child is discussed. The mother's serum STH level increased in the course of the pregnancy progressively despite the treatment and fell after the delivery while the child's STH levels were normal.

[Vaginal echography in extrauterine pregnancy]. / Vaginalna ekhografiia pri izvunmatochna bremennost.

Twenty eight women with suspicion for extrauterine pregnancy were examined by a vaginal transducer. Extrauterine pregnancy was diagnosed in 18 of them, which was confirmed at the operation. There were no echographic data for tubal pregnancy in 10 of the women. Their further follow-up rejected the presence of extrauterine pregnancy. Three tubal pregnancies were discovered by routine monitoring of ovarian cycles. The immediate proximity of the vaginal transducer to the examined organs in the pelvis gives a possibility for exact topical diagnosis.

[Echographic diagnosis of ovulation in healthy women]. / Ekhografska diagnoza na ovulatsiiata pri zdravi zheni.

Dynamic echographic changes in measures of the uterus, uterine mucosa, ovaries and dominant follicle during normal ovulatory menstrual cycle were established in 16 multiparas and 17 nulliparas. All measures undergo characteristic changes as they increase during follicular phase of the cycle and reach their maximum paraovulatorily. For establishment of ovulation the changes in anterior-posterior size of the uterus, uterine mucosa, diameter of the dominant follicle and qualitative changes, occurring in it, are of the greatest significance. Mathematical models are made, which allow a comparison and prognosis of the changes in the internal genital organs of a woman in respect to the ovulation.