Uncontrolled Acute Intermittent Porphyria as a Cause of Spontaneous Abortion.

INTRODUCTION: The association of acute intermitetn porphyria (AIP) with pregnancy and as a cause of spontaneous abortion is rare. AIM: To show a case of AIP known before pregnancy in a patient who had a spontaneous abortion. CASE REPORT: A gynecologist examined 26-year-old patient in the 8th week of gestation, due to initial spontaneous abortion, abdominal pain, constipation, muscle weakness, vomiting and dark colour of urine. Her therapy was dydrogesterone. In consultation with an anesthesiologist, a short intravenous anesthesia, vacuum aspiration, and curettage were performed.During hospitalization, the patient ceased to take harmful drugs and she was given haemarginate, glucose and symptomatic drugs, and she recovered completely. CONCLUSION: Treatment of threatened spontaneous abortion in AIP remains the subject of dilemma and controversy, and future research is needed.

Ethical and Legal Dilemmas Around Termination of Pregnancy for Severe Fetal Hydrocephalus, Spina Bifida Aperta and Meningomyelocoella.

INTRODUCTION: There are many ethical and moral dilemmas regarding the termination of pregnancy(TOP) with severe fetal anomalies. AIM: Our aim is to present a case of severe fetal hydrocephalus (HCP), spina bifida aperta and, meningomyelocoella (MMC). CASE REPORT: A gynecologist examined a 23-year-old patient with vital pregnancy of 24/25 week of gestation (WG) with the anomaly of the fetus. At the Perinatological Medical Advisory Board, a decision was made that the pregnancy should be continued and monitored bearing in mind that pregnancy exceeded the legal framework for TOP. Medical Advisory Board's ultrasound examination showed the following: severe hydrocephalus (HCP), spina bifida aperta, hyperehogen intestine, pes equinovarus. Via multidisciplinary consultation it was decided to make a delivery with the elective caesarian section (CS) causing as little trauma to the fetus as possible, with 37 WG completed due to the pelvic presentation and fetal anomalies. The patient gave birth via CS to a live female newborn-birth weight 3920 grams, birth length 56 cm, head circumference 48 cm, and Apgar score 8/8. The head was hydrocephalic with spaced suture. There was thoracolumbar defect of spina bifida aperta and meningomyelocele (MMC) 10x12 cm in size. An urgent surgical procedure - the external ventricular derivation of the liquor, and then the successful resection and plastic meningomyelocele was performed by a team of neuro and plastic surgeons. During the fourth postoperative day due to a suspicion of abscess collection and febrility of the mother a relaparotomy is performed and the abscess collection of Retzius space was found. Due to the fall in blood count, blood transfusion in a total dose of 580 ml was given. The patient was discharged on a home treatment as she had a regular general and local status. After the surgery, the condition of the newborn resulted in deterioration, the progression of HCP and dehiscence of head wounds and the thoracolumbar region, in spite of all the measures taken. At that time a decision was made to provide palliative care and this decision was conveyed to the mother. The child had a prolonged apnoeic episode and was not resuscitated. The child died in hospital after surviving for two months postpartum. CONCLUSION: Indication of TOP based on fetal anomalies could be a medical decision but also a personal moral choice of the mother related to legal rules, socio-cultural values and religious beliefs.