Cesarean Scar Pregnancy Complicated with Placenta Percreta.

INTRODUCTION: Cesarean scar pregnancy is potentially life-threatening condition because of heavy complications and includes adherent placenta: accreta, increta or percreta as a result of deep placental invasion. AIM: To present a rare case of ectopic cesarean scar pregnancy combined with placenta percreta in 38-year old woman who undergone previous cesarean section delivery. CASE REPORT: A multiparous woman aged 38 years with prior cesarean section delivery, admitted first time to the Clinic in 7th week of gestation, due to her medical record (light bleeding). Diagnosis was: graviditas hbd 7, gemellar pregnancy, blighted ovum gemellus I, graviditas isthmico-cervicalis gemellus II. Due to diagnosis it was performed vacuum aspiration et curettage and woman leaved hospital same day. One month later same woman was admitted again to the Clinic due to bleeding and ultrasound finding suspicious to residual trophoblastic tissue. Beta human chorionic gonadotropin serum concentration at the day of admittance was 8,419 IU/ml. Ultrasound finding showed inhomogeneous supracervical formation with dimension 2,73x1,89 cm with increased vascularity and resistant index 0.36 and suspicious placenta increta. We made decision to surgery, and performed hysterectomy in view of heavy intraoperative haemorrhage. Woman was discharged at fifth day after surgery in good condition. Histological finding showed cervical pregnancy complicated with placenta percreta parietis isthmicocervicalis of the uterus. CONCLUSION: We showed the importance of early and opportune diagnosis of cervical pregnancy specially complicated with one of kind of throphoblastic disease, to prevent life-threatening complication.

Complete Molar Pregnancy in Posmenopausal Woman-a Case Report.

INTRODUCTION: Gestational trophoblastic desease (GTD) is disease typical for reproductive period of women and is extremly rare in postmenopausal period of woman's life. AIM: To present a rare case of mollar pregnancy in 57 years of age postmenopausal woman. CASE REPORT: A multiparous woman aged 57 years, and two yars after last menstrual bleeding, was admitted at Clinic, due to hyperplastic endometrium findings and moderate prolonged postmenopausal uterine bleeding. Due to clinical simptoms we performed diagnostic exploratice curettage. During that intervention heavy bleeding was developed resulting in spontaneous expulsion of tumorous mass wich macroscopic looked as a mollar tissue. Imediatelly after intervention level of ß HCG was 193,057mlU/mL. Due to very high level of ß HCG patient was taken to laparotomy and during the surgery dicision was made to perform total abdominal hysterectomy with bilateral adnexectomy. Eight day after surgery patient was discharged from Clinic in good condition. Hystopathological examination of material obtained by explorative curettage and uterus showed complete mollar pregnancy. Controlled level of ß HCG was 1,996 mlU/mL fifth day after surgery. CONCLUSION: Although molar pregnancy in postmenopausal period of woman's life is very rare disorder, because of potentialy heavy complications it is very important to recognise this disorder at time, to prevent delay of treatment.

Cesarean Section Rate Analysis in University Hospital Tuzla - According to Robson's Classification.

OBJECTIVE: For last decades, there has public concern about increasing Cesarean Section (CS) rates, and it is an issue of international public health concern. According to World Health Organisation (WHO) there is no justification to have more than 10-15% CS births. WHO proposes the Robson ten-group classification, as a global standard for assessing, monitoring and comparing cesarean section rates. The aim of this study was to investigate Cesarean section rate at University Hospital Tuzla, Bosnia and Herzegovina. METHODS: Cross sectional study was conducted for one-year period, 2015. Statistical analysis and graph-table presentation was performed using Excel 2010 and Microsoft Office programs. RESULTS: Out of 3,672 births, a total of 936 births were performed by CS. Percentage of the total number of CS to the total birth number was 25,47%. According to Robson classification, the largest was group 5 with relative contribution of 29,80%. On second and third place were group 1 and 2 with relative contribution of 26,06% and 15,78% respectively. Groups 1, 2, 5 made account of realtive contribution of 71,65%. All other groups had entirely relative contribution of 28,35%. CONCLUSION: Robson 10-group classification provides easy way in collecting information about CS rate. It is important that efforts to reduce the overall CS rate should focus on reducing the primary CS. Data from our study confirm this attitude.

LOW PRETERM BIRTH RATE WITH DECREASING EARLY NEONATAL MORTALITY IN BOSNIA AND HERZEGOVINA DURING 2007-2014.

THE AIM: of the study was to determine the situation of preterm births and early neonatal mortality during 2007-2014 in Tuzla Canton, Bosnia and Herzegovina. METHODS: The study covers a 8-year period and is based on the protocols at the Tuzla Clinic for Gynecology and Obstetrics that covers all birth in Tuzla Canton area. We analyzed the gestational age of all newborns and recorded the number of neonatal deaths in the first week after birth. Demographics, pregnancy and birth characteristics were collected from the maternal records. RESULTS: The total number of births in the period was 32738. Preterm birth was identified in 2401 (7.3%) cases with 12,5% occurring before 32 gestational weeks and 64% in 35-36 gestational weeks. The mothers of the 24-31 gws preterm group were significantly younger that those in the 32-36 group. In the 32-36 group there were significantly greater proportions of mothers with assisted reproductive technology and pre-eclampsia and 16.7% was medical induced preterm births versus 11.4 % in the 24-31 PTB group, p<0.05. The incidence of PTB did no vary significantly during the period, the lowest rate was found in 2010 (6.4%). A total of 221 children died giving a early mortality rate of 6.8 per 1000 live born over the 8 years. The majority 156 dying infants (70.6%) were preterm, only 5.7% died being born in the 35-36 gestational week (5.9 per 1000). Overall the preterm early mortality (7.3 per 1000) has shown a decreasing tendency during the latter years. CONCLUSION: During the last 8 years there have been no significant decline in preterm birth in the Tuzla region while a decline in early neonatal death has been registered.

GIANT AGGRESSIVE ANGIOMYXOMA OF THE VULVA: CASE REPORT.

A 57-year-old multiparous housewife was hospitalized at University Clinical Center with painless, ulcerated, huge tumor of the vulva, which had progressively increased in size during the last five years. It was a firm, ulcerated mass involving the left vulva and measuring 35 cm in diameter. The vaginal orifice was deviated to the right by the tumor. The adnexa and the uterus were normal. The patient underwent total excision of the tumor in general anesthesia, and histology confirmed aggressive angiomyxoma. She had an uneventful postoperative period with satisfactory healing of the wound.

Maternal serum progesterone-induced blocking factor (PIBF) in the prediction of preterm birth.

The objective of this study was to analyze the maternal serum concentration of progesterone-induced blocking factor (PIBF) with regard to the prediction and the interval between sampling and the onset of preterm birth. A prospective study was conducted on a sample of 37 women with threatened pre-term birth and 41 healthy pregnant women between the 24th and 28th gestational weeks. Out of 37 patients with threatened preterm birth 11 delivered pre-term and three groups of patients were formed: the preterm delivery group, patients with threatened preterm delivery, and healthy pregnant women. In samples that were taken within 5 days before labor started (6/11, 54.5%), PIBF concentrations were significantly lower than in those obtained more than 5 days before labor (5/11, 45.5%; the mean interval between sampling and the onset of labor was 4.1 ± 1.8 days). Multiple regression analysis of the individual contributions of each observed parameter for preterm delivery demonstrated the significant contribution of a lack of PIBF to preterm birth (p = 0.002). Receiver operating characteristics (ROC) analysis was performed to evaluate the diagnostic accuracy of PIBF for the prediction of preterm birth of women with symptoms of pre-term delivery. The PIBF demonstrated an excellent diagnostic value in the prediction of preterm birth with an area under the ROC curve (AUC) of 0.956 (95% CI = 0.884-0.989; p < 0.0001). Our data suggest that pregnancy termination can be predicted by lower than normal pregnancy PIBF values within 5 days before labor and can contribute to the diagnosis of preterm birth.

Angiomyofibroblastoma of the vaginal portion.

INTRODUCTION: Angiomyofibroblastoma is a tumor which is consists of two components: blood vessels and stromal cells, with always prominent vascular component. Angiomyofibroblastoma is benign tumor, but in literature is reported a case of recurrence and one case with sarcomatous transformation, which shoved that these tumors may rarely be associated with malignant component. CASE REPORT: A 78-year-old multiparous housewife was hospitalized at University Clinical Center because of painless, asymptomatic tumor of vaginal portion (posterior side). Tumor size was 7 millimeters in diameter. Internal genital organs did not present abnormalities. The patient underwent operative removal of the tumor and went to home at some day. At the histological examination the tumor presented as a angiomyofibroblastoma cervices uteri.

Perinatal mortality during fifteen-year period in Tuzla Canton, Bosnia and Herzegovina.

THE AIM: To determine the incidence of perinatal mortality, as well as the frequency of premature deliveries. METHODS: We analyzed the data of birth protocol at the Clinics for Gynecology and Obstetrition at the University Clinical Centre in Tuzla in period 1992-2006. RESULTS: Perinatal mortality gradually declines in the period of 1992-2000. The decline owns mostly to early neonatal mortality more than to fetal which also shows the trend of decrease. During the first analyzed years (1992 and 1993) the incidence of premature deliveries was below 10% but that number increased during 1994 and 1995 (15.8%). The most interesting finding is that the highest level of incidence of premature deliveries was registered in the first postwar year--1996 (16.4%) when we also noted the largest number of deliveries for the analyzed period and most of which were finished between 32 and 36 weeks. The frequency of delivery of underweight babies (500-2499 g) was between 3.8 to 12.2%. The highest frequency was registered during the 1994 and 1995 when it reached 12.2%. The frequency of delivery of extremely underweight babies (500-999 g) for the analyzed period was about 0.1% with significant increase during the wartime (1995 even 0.6%). CONCLUSION: We found that during the period of 15 years a significant decline of perinatal mortality is registered, due to early neonatal death. Limited accessibility and quality of perinatal health care during the war period had detrimental effects on the healt and survival of newborns.

The Misgav-Ladach method of cesarean section: a step forward in operative technique in obstetrics.

OBJECTIVE: The objective of this study is to compare the intraoperative and short-term outcomes of two cesarean techniques: the modified Misgav-Ladach and the Pfannenstiel-Kerr. METHODS: We performed a prospective observational cohort study of women undergoing a primary cesarean at the Clinic for Obstetric and Gynecology Tuzla, Bosnia and Herzegovina, between January 2003 and December 2011. The two cesarean techniques were compared for intraoperative and short terms outcomes. RESULTS: A total of 4,944 women were included in this study, 4,336 allocated to the modified Misgav-Ladach and 608 to the Pfannenstiel-Kerr techniques. The rate of modified Misgav-Ladach increased from 74 % in 2003 to 99 % in 2011. The modified Misgav-Ladach technique was associated with a shorter operative time (13.3 min ± 7.4 vs. 19.1 min ± 6.8, p < 0.05), as well as significantly less surgical material (3.5 ± 2.5 vs. 7.9 ± 2.1, p < 0.05). The modified Misgav-Ladach technique was also associated with lower analgesic requirements, lower rates of febrile morbidity and wound infection compared to the Pfannenstiel-Kerr technique (p < 0.05). No significant differences were observed in the incidence of endometritis, wound dehiscence, bowel restitution, postoperative antibiotic use, and hospital stay. CONCLUSION: The modified Misgav-Ladach technique is associated with a shorter operative time than Pfannenstiel-Kerr and might lead to better postoperative outcomes.

Risk of uterine rupture following locked vs unlocked single-layer closure.

OBJECTIVE: To compare the rate of uterine scar disruption after a locked versus an unlocked single-layer closure of the hysterotomy incision at a previous cesarean. METHODS: A retrospective cohort study in a population where both locked and unlocked single-layer closure are commonly used. All singleton pregnancies at 24 weeks' gestation or more with a previous single cesarean were included. Rate of uterine scar disruption (complete uterine rupture and uterine scar dehiscence) were compared between women with a previous locked and those with a previous unlocked single-layer closure of the uterus. RESULTS: Out of 388 women included in the study, 272 had a previous unlocked single-layer closure and 116 had a locked single-layer closure. We found no significant difference in the rate of uterine scar disruption between the two groups (5.9% vs 8.6%, p = 0.32). CONCLUSION: Locking a single-layer closure was not associated with an increase rate of uterine scar disruption at the next pregnancy in our retrospective analysis. A randomized trial should be performed.