ULTRASOUND DIAGNOSIS OF MACROSOMIA AMONG WOMEN WITH GESTATIONAL DIABETES - REVIEW OF THE LITERATURE.

Pregnancies burdened with gestational diabetes (GDM) are more likely to end in birth of a macrosomic child, where the frequency of operative termination of pregnancy is more common, accompanied with more complications and injuries of both mother and child in comparison to the general population. The need to calculate fetal weight right before delivery has led to the development of numerous methods for greater estimation accuracy. We reviewed the related literature from 1980 to 2020, using the terms macrosomia, ultrasound assessment, gestational diabetes, and relevant articles were considered in preparation of this article. The most frequently used methods are based on two-dimensional ultrasound measurements of individual fetal biometric parameters and their combination in a mathematical regression model. Some methods involve the addition of other mother and child conditions to increase reliability of the method in recognizing macrosomia. In daily work, especially with pregnant women suffering from GDM, it is necessary to have reliable data on the estimated fetal weight before making the correct clinical decision on how to terminate the pregnancy. In this regard, we bring a review of the literature related to the assessment of fetal macrosomia, especially in women with GDM.

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases.

BACKGROUND: Spontaneous liver rupture in pregnancy is often unrecognized, highly lethal, and not completely understood. The goal was to summarize and define the etiology, risk factors, clinical presentation, appropriate diagnostic methods, and therapeutic options for spontaneous hepatic rupture during pregnancy/puerperium (SHRP) complicated by the hypertensive disorder. METHODS: Literature search of all full-text articles included PubMed (1946-2021), PubMed Central (1900-2021), and Google Scholar. Case reports of a spontaneous hepatic rupture or liver hematoma during pregnancy or puerperium as a complication of hypertensive disorders (preeclampsia, eclampsia, HELLP syndrome) were searched. There was no restriction of language to collect the cases. Additional cases were identified by reviewing references of retrieved studies. PRISMA guidelines for the data extraction and quality assessment were applied. RESULTS: Three hundred and ninety-one cases were collected. The median maternal age was 31 (range 17-48) years; 36.6% were nulliparous. Most (83.4%) occurred in the third trimester. Maternal and fetal mortality was 22.1% and 37.2%, respectively. Maternal and fetal mortality was significantly higher 1) before the year 1990, 2) with maternal hemodynamic instability, and 3) eclampsia. The most important risk factors for SHRP were preeclampsia and HELLP syndrome. Most women had right lobe affected (70.9%), followed by both lobes in 22.1% and left lobe in 6.9%. The most common surgical procedure was liver packing. Liver transplantation was performed in 4.7% with 100% survival. Maternal mortality with liver embolization was 3.0%. Higher gestational age increases fetal survival. CONCLUSION: The diagnosis and treatment of SHRP are often delayed, leading to high maternal and fetal mortality. SHRP should be excluded in hemodynamically unstable patients with preeclampsia/eclampsia or HELLP syndrome and right upper abdominal pain. Liver embolization and liver transplantation contribute to maternal survival. Maternal and fetal mortality was significantly higher before the year 1990. Hemodynamic instability, preeclampsia, and eclampsia have a significant negative influence on maternal survival. LEVEL OF EVIDENCE: Level V.

Diagnostic accuracy, sensitivity, and specificity of CT pulmonary artery to aorta diameter ratio in screening for pulmonary hypertension in end-stage COPD patients.

AIM: To determine the diagnostic accuracy of pulmonary artery to aorta ratio in screening for pulmonary hypertension in advanced chronic obstructive pulmonary disease (COPD) patients. METHODS: A prospective, diagnostic study was conducted in University Hospital Center Zagreb between January 2015 and March 2018. The study enrolled 100 patients who consecutively underwent chest computed tomography (CT), echocardiographic exam, and right heart catheterization. Two independent observers measured pulmonary artery and ascending aorta diameters. The correlation between the ratio and mean pulmonary artery pressure, measured invasively, was assessed. Patients with echocardiographic signs of moderate systolic or diastolic left ventricular dysfunction were excluded (n=44). RESULTS: Sixty-six patients (55.5% men), with a median age of 61, were identified. Median forced expiratory volume during the first second (FEV1) was 34±12, FEV1/forced vital capacity <0.70. Patients with and without pulmonary hypertension had pulmonary artery diameter of 36±7 mm and 27±4.6 mm, respectively (P<0.001). Median pulmonary artery/aorta (PA/A) ratios for patients with and without pulmonary hypertension were 1.05 and 0.81, respectively (P<0.001). PA/A ratio above 0.95 was an independent predictor of pulmonary hypertension with a specificity of 100% and a sensitivity of 74.51% (area under the curve=0.882; standard error=0.041; P<0.001). CONCLUSION: PA/A ratio as measured on chest CT images can be used as a screening tool instead of echocardiography.

Painful and Itchy Dermatoses Carry the Highest Psychological Burden for Dermatovenereological Patients.

BACKGROUND: Most dermatovenereological diseases are not life-threatening but nevertheless are highly prevalent disorders. Psychosocial aspects of skin diseases and physical symptoms strongly influence patient's quality of life (QoL) which results in the development of different coping mechanisms in patient's behaviour. Development of psychiatric comorbidity in patients with skin diseases is well known. On the other hand, little is known about psychological comorbidity associated with dermatovenereological diseases. Aims of this study were to investigate QoL and psychological burden among dermatovenereological patients. SUBJECTS AND METHODS: Two hundred and ninety patients suffering from different dermatological and venereological diseases participated in the study, divided into three study groups: itchy/painful dermatoses, non-itchy/non-painful dermatoses and venereological diseases. Participants completed standardized psychological questionnaires: Dermatology Specific Quality of Life (DSQL), Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI). Intensity of the disease and localisation of the lesions were also assessed. RESULTS: Physical aspect of QoL was mostly influenced by itchy/painful dermatoses but psychological aspect and everyday activities and choices were mostly affected by patients with non-itchy/non-painful dermatoses and venereological diseases. 4.1% of participants had serious depressive symptoms, 11.5% had high and very high anxiety symptoms as state and 15.6% as trait. However, participants with severe skin conditions were more depressed, while participants with always and sometimes exposed lesions were more anxious. CONCLUSION: It is essential to recognise subgroups of dermatovenereological patients whose treatment approach should be interdisciplinary. Further studies are needed to detect psychosocial needs of patients with venereological diseases.

Diagnostic accuracy of modified Hadlock formula for fetal macrosomia in women with gestational diabetes and pregnancy weight gain above recommended.

OBJECTIVES: Women with gestational diabetes (GDM) and weight gain during pregnancy above recommended more often give birth to macrosomic children. The goal of this study was to evaluate the diagnostic accuracy of the modified formula for ultrasound assessment of fetal weight created in a pilot study using a similar specimen in comparison to the Hadlock-2 formula. METHODS: This is a prospective, cohort, applicative, observational, quantitative, and analytical study, which included 213 pregnant women with a singleton pregnancy, GDM, and pregnancy weight gain above recommended. Participants were consecutively followed in the time period between July 1st, 2016, and August 31st, 2020. Ultrasound estimations were made within three days before the delivery. Fetal weights estimated using both formulas were compared to the newborns' weights. RESULTS: A total of 133 fetal weight estimations were made. In comparison to the newborns' weight modified formula had significantly smaller deviation in weight estimation compared to the Hadlock-2 formula, higher frequency of deviation within 5% of newborns weights (78.2% [95% CI=0.74-0.83] vs. 60.2%), smaller frequency of deviations from 5 to 10% (19.5 vs. 33.8%) and above 10%, which was even more significant among macrosomic children. There were 36/50 (72%) correctly diagnosed cases of macrosomia by modified and 33/50 (66%) by Hadlock-2 formula. Area under the curve (AUC) for the modified formula was 0.854 (95% CI=0.776-0.932), and for the Hadlock-2 formula 0.824 (95% CI=0.740-0.908). The positive predictive value of the modified formula was 81.81%, the negative 97.91%. CONCLUSIONS: In cases of greater fetal weights, the modified formula showed greater precision.

Risk factors for subsidence of modular fluted tapered stem implanted by using transfemoral Wagner approach during revision hip arthroplasty.

PURPOSE: To determine clinical and radiographic risk factors for the vertical subsidence of modular fluted tapered stems implanted using the transfemoral Wagner approach in a cohort of revision hip arthroplasties. METHODS: A retrospective review of a single-centre surgical registry was performed. Patients who underwent a revision total hip arthroplasty, in which the uncemented modular fluted tapered stem (REVISION Hip/Anca-Ti6Al4V, LimaCorporate, Udine, Italy) was implanted using the transfemoral Wagner approach, were identified. Patient's demographic data, clinical and radiographic outcomes and post-operative complications were assessed. As a significant subsidence, a 5-mm cut-off was chosen. RESULTS: We identified 278 revision hip arthroplasties with a mean follow-up of 35 months. The median of subsidence in the group of 5 mm and less was 2 mm, and 17 mm in the group of subsidence of 5 mm and more. A negative correlation was found between the stem subsidence and the length of good contact between the medial and lateral cortical bone and the stem (medial, - 0.248; P < 0.001, lateral, 0.284; P < 0.001). For 200 mm stems, the percentage of good contact between femoral parts of stem and bone on medial side was 40.5% (81.0 mm) for patients with subsidence of five or less mm, and 30% (60.0 mm) for lateral side. For 140 mm stems, the percentage was 52.86% (74.0 mm) for medial side and 40.36% (56.5 mm) for lateral side. A neck length was shown to correlate significantly with the stem subsidence (P = 0.004). CONCLUSION: It is crucial to provide good contact between the bilateral cortical bone and stem, and, if possible, to select implant constructs with shorter femoral necks, in order to reduce subsidence and to ensure longer implant survivorship.

[SATISFACTION OF YOUNG DOCTORS IN CROATIA: ARE WE HEADING IN THE RIGHT DIRECTION]? / ZADOVOLJSTVO MLADIH LIJECNIKA U REPUBLICI HRVATSKOJ: IDEMO LI U PRAVOM SMJERU?

Introduction: The satisfaction of junior medical doctors is primarily associated with the training they receive during the residency period and working conditions. Given a considerable brain-drain of medical doctors from the Republic of Croatia, the present research focused on the evaluation of the satisfaction of junior medical doctors. Methodology: The Junior Doctors Committee of the Croatian Medical Chamber prepared a questionnaire on the satisfaction of junior doctors. The relevant questionnaire was available for filling in online in the period from February 1 to March 20, 2016. Results: The questionnaire was completed by 1,531 persons aged between 29 and 35 (mean age 32) of which 67% were females. A 58% of respondents would leave the Republic of Croatia if offered an opportunity. The main reasons for leaving the country include better working conditions (74%), well-regulated healthcare system (64%) and higher wages (64%). In case of staying in the country, their future professional status and development would remain unaltered (44%). Conclusion: The questionnaire results show a high level of dissatisfaction with the healthcare system, some segments of the specialist training and the mentor role. The analysis of factors affecting the satisfaction of junior doctors will facilitate the preparation and adoption of measures aiming to mitigate the above-mentioned trend.

Current Preventive Strategies for Preovulatory Progesterone Elevation During Ovarian Stimulation for In Vitro Fertilization

The purpose of this review is to present contemporary measures for preventing the increase in preovulatory progesterone (P) and its adverse effects on ovarian stimulation in in vitro fertilization (IVF). For the last 20 years, the increase of preovulatory P has been a topic of numerous discussions because its role is not fully understood in terms of its impact on pregnancy outcome after IVF. Some studies failed to establish a connection between the preovulatory P increase and successful IVF outcome regardless of the level of P, while, conversely, most other studies have reported on adverse effects of elevated P concentrations. Current strategies to prevent the increase in preovulatory P include an individualized approach with the use of mild stimulation protocols and early application of human chorionic gonadotropin for ovulation induction among good responders, delay in the transfer of fresh embryos from 3rd to 5th day, and cryopreservation of all embryos with the thawed embryo transfer in the natural cycle. Nevertheless, further studies are needed to confirm the current preventive methods or enable the application of new strategies in order to lower or eliminate the detrimental effects of preovulatory P rise during ovarian stimulation in IVF.

INFLUENCE OF MALE OBESITY ON FERTILITY.

The aim of this review is to analyze current diagnostic approaches to obesity in adult men, the potential mechanisms linking obesity to infertility, and treatment options aimed at improving reproductive health. Obesity has become a worldwide epidemic with the estimated prevalence increasing from 28.8% to 36.9% between 1980 and 2013. In terms of diagnosis, numerous simple techniques have been developed including body mass index, waist to hip ratio, waist circumference, bioelectrical impedance analysis, ultrasound and skinfold measurements. Additionally, several other less available but more accurate techniques have been suggested, such as air displacement plethysmography, dual energy x-ray absorptiometry, computed tomography and magnetic resonance imaging. In addition to cardiovascular and other disorders, male obesity can negatively affect the male reproductive potential through abnormal reproductive hormone levels, reduced semen quality, increased release of adipose-derived hormones and adipokines, as well as thermal, genetic and sexual mechanisms. In the management of obesity related male infertility, natural weight loss is the cornerstone and regular exercise the first-line treatment. Although bariatric surgery results in greater improvements in weight loss outcomes when compared to non-surgical interventions, further research is required to clarify its overall influence on male fertility.

Perinatal Health Statistics as the Basis for Perinatal Quality Assessment in Croatia.

CONTEXT: Perinatal mortality indicators are considered the most important measures of perinatal outcome. The indicators reliability depends on births and deaths reporting and recording. Many publications focus on perinatal deaths underreporting and misclassification, disabling proper international comparisons. OBJECTIVE: Description of perinatal health care quality assessment key indicators in Croatia. METHODS: Retrospective review of reports from all maternities from 2001 to 2014. RESULTS: According to reporting criteria for birth weight ≥500 g, perinatal mortality (PNM) was reduced by 31%, fetal mortality (FM) by 32%, and early neonatal mortality (ENM) by 29%. According to reporting criteria for ≥1000 g, PNM was reduced by 43%, FM by 36%, and ENM by 54%. PNM in ≥22 weeks' (wks) gestational age (GA) was reduced by 28%, FM by 30%, and ENM by 26%. The proportion of FM at 32-36 wks GA and at term was the highest between all GA subgroups, as opposed to ENM with the highest proportion in 22-27 wks GA. Through the period, the maternal mortality ratio varied from 2.4 to 14.3/100,000 live births. The process indicators have been increased in number by more than half since 2001, the caesarean deliveries from 11.9% in 2001 to 19.6% in 2014. CONCLUSIONS: The comprehensive perinatal health monitoring represents the basis for the perinatal quality assessment.

Fertility preservation options in breast cancer patients.

The purpose of this review is to analyse current options for fertility preservation in young women with breast cancer (BC). Considering an increasing number of BC survivors, owing to improvements in cancer treatment and delaying of childbearing, fertility preservation appears to be an important issue. Current fertility preservation options in BC survivors range from well-established standard techniques to experimental or investigational interventions. Among the standard options, random-start ovarian stimulation protocol represents a new technique, which significantly decreases the total time of the in vitro fertilisation cycle. However, in patients with oestrogen-sensitive tumours, stimulation protocols using aromatase inhibitors are currently preferred over tamoxifen regimens. Cryopreservation of embryos and oocytes are nowadays deemed the most successful techniques for fertility preservation in BC patients. GnRH agonists during chemotherapy represent an experimental method for fertility preservation due to conflicting long-term outcome results regarding its safety and efficacy. Cryopreservation of ovarian tissue, in vitro maturation of immature oocytes and other strategies are considered experimental and should only be offered within the context of a clinical trial. An early pretreatment referral to reproductive endocrinologists and oncologists should be suggested to young BC women at risk of infertility, concerning the risks and benefits of fertility preservation options.

Arachidonic and docosahexaenoic acid in the blood of a mother and umbilical vein in diabetic pregnant women.

OBJECTIVE: The aim of the study was to determine the total concentration of fatty acids (FAs) in the maternal vein serum and in the umbilical vein serum in pregnant women suffering from Type 1 diabetes compared to healthy women. Additional goal was to determine the percentages of arachidonic (AA) and docosahexaenoic acid (DHA) in comparison to the total concentration of FAs. METHODS: The study included 63 pregnant women, 32 suffering from Type 1 diabetes and 31 healthy pregnant women. Extraction of total lipids was performed using gas chromatography. RESULTS: There was statistically significant difference in the total FAs concentration in the maternal vein serum and the umbilical vein serum between the two groups. There was a statistically significant higher concentration of total FAs in the maternal and umbilical vein serum of the diabetic group. Higher AA and DHA concentrations were found in the maternal vein serum compared to an umbilical vein serum of the diabetic group. CONCLUSION: No difference was found in AA and DHA percentages in the maternal or in the umbilical vein serum of diabetic pregnant women. Despite of T1DM, a good metabolic control leads to insignificant changes in the AA and DHA levels in diabetic pregnancy.

Intermittent epidural TOP-UPS vs. patient control epidural analgesia during labor.

Pain during labor and delivery is often very unpleasant and stressful for the parturients. Patient controlled epidural analgesia (PCEA) has been found to be both safe and effective, providing optimal pain relief and allowing women to participate in their own analgesia). Compared to other epidural techniques, intermittent epidural top-ups and continuous epidural analgesia (CEA), PCEA uses diluted local anesthetic solutions with less motor block and less unscheduled clinician interventions. The purpose of our study was to compare intermittent bolus epidural top-ups and PCEA in labor. Sixty ASA I patients who requested epidural analgesia for labor and had written consent were included in the study. 30 patients in the first group received intermittent bolus epidural top-ups, while patients in the second group received PCEA. We evaluated duration of labor, maternal sense of pain using VAS scale and maternal satisfaction during fetal descent in both groups. We found that the duration of labor was significantly shorter and maternal sense of pain was lower in the PCEA group than in the group receiving epidural bolus top-ups. There were no differences between groups in maternal satisfaction during fetal descent.

Successful delivery of fetus with fetal inherited thrombophilia after two fetal deaths.

A pregnant woman with inherited thrombophilia (factor II mutation--20210A) had two late pregnancy losses. The first pregnancy was not well documented, but the second pregnancy was complicated by fetal thrombophilia and umbilical artery thrombosis, proven after fetal death. During the third pregnancy enoxaparine was introduced in the therapy and early amniocentesis was performed. Fetal thrombophilia was proven again. Early delivery was induced and performed with no complications, resulting in a live healthy infant. A history of miscarriages or recurrent fetal loss should raise suspicion of thrombophilia as a potential cause. It is debatable whether amniocentesis in pursuit of fetal thrombophilia should be performed and whether this will lead to a better perinatal outcome. When fetal thrombophilia is diagnosed, an earlier induction of delivery should be considered, taking into account the fetal extrauterine viability. The aforementioned approach of early delivery in cases of inherited fetal thrombophilia could be a possible solution for better perinatal outcomes.

Pathological pregnancy and psychological symptoms in women.

Pregnancy is followed by many physiologic, organic and psychological changes and disorders, which can become more serious in pregnancy followed by complications, especially in women with pathological conditions during pregnancy. The purpose of this study was to find out and analyze the prevalence and intensity of psychological disorders in women with pathological conditions during pregnancy and compare it with conditions in pregnant women who had normal development of pregnancy. The research is approved by the Ethical committee of the Mostar University Hospital Center, and it was made in accordance with Helsinki declaration and good clinical practices. The research conducted section for pathology of pregnancy of Department for gynecology and obstetrics of the Mostar University Hospital Center. It included 82 pregnant women with disorders in pregnancy developement and control group consisted of pregnant women who had normal development of pregnancy. The research work was conducted from September 2007 to August 2008 in Mostar University Hospital Center. Pregnant women had Standard and laboratory tests, Ultrasound. CTG examinations were done for all pregnant women and additional tests for those women with complications during pregnancy. Pregnant women completed sociobiographical, obstetrical-clinical and psychological SCL 90-R questionnaire. Pregnant women with pathological pregnancy exibited significantly more psychological symptoms in comparison to pregnant women with normal pregnancy (p < 0.001 to p = 0.004). Frequency and intensity of psychical symptoms and disorders statisticly are more characteristic in pathological pregnancy (61%/40.6%). The statistical data indicate a significantly higher score of psychological disorders in those pregnant women with primary school education (p = 0.050), those who take more than 60% carbohydrates (p = 0.001), those with pathological CTG records (p < 0.001), those with pathological ultrasound results (p < 0.001 to 0.216) and those pregnant women with medium obesity and obesity (p = 0.046). Body mass index (BMI) during normal pregnancy development is lower (p = 0.002) but the levels of glucose, triglycerides, cholesterol, HDL and LDL in blood are higher Blood pressure in pregnant women with pathological pregnancy was statistically significantly higher (p < 0.001). Diagnostic criteria for the metabolic syndrome were found in 19 pregnant women with the pathological pregnancy. Statistically, in those women, a significantly higher appearance of psychological symptoms and disorders was observed in comparison to the pregnant women without metabolic syndrome (p < 0.001). The research has shown that 87.8% from all pregnant women included in this study have been hospitalized due to premature birth, hypertensive disorders, and diabetes in pregnancy, and also due to bleeding in the second and third trimester of pregnancy.

Prevalence, treatment and control of hypertension in a Croatian endemic nephropathy area.

BACKGROUND: Hypertension is not considered to be a characteristic of endemic nephropathy (EN). Recent observations suggested that it might be more prevalent than it was reported before. AIM: The aim of our study was to analyze prevalence, treatment and control of hypertension in a Croatian endemic area. METHODS: In the present cross-sectional study, 1,602 farmers were enrolled, 1,246 from EN and 356 from control villages. Epidemiological and medical histories were taken and clinical and laboratory examinations performed for kidney function. Blood pressure was measured following the ESH/ESC guidelines. RESULTS: The prevalence of hypertension in EN villages was higher than in control (50.8 vs. 46.5%, p = 0.005). There was no difference in overall treatment, control of all and treated hypertensives between the villages. In all villages, women were treated more than men (EN 41.6 vs. 28.4%, p < 0.001; control 46.4 vs. 27.3%, p < 0.001), but better control of treated was achieved in men (EN 24.7 vs. 17.4%, p = 0.002; control 29.6 vs. 15.5%, p = 0.002). Women had lower income and level of education than men (p < 0.01). CONCLUSION: Hypertension is highly prevalent in endemic villages. In all villages, men had better blood pressure control despite being treated less. This finding could be explained by poorer education and income in women.

Comparison of C-reactive protein and procalcitonin as predictors of postoperative infectious complications after elective colorectal surgery.

AIM: To assess diagnostic value of perioperative procalcitonin (PCT) levels compared to C-reactive protein (CRP) levels in early detection of infectious complications following colorectal surgery. METHODS: This prospective observational study included 79 patients undergoing elective colorectal surgery. White blood cell count, CRP, and PCT were measured preoperatively and on postoperative days (POD) 1, 2, 3, 5, and patients were followed for postoperative complications. Diagnostic accuracy of CRP and PCT values on each day was analyzed by the receiver operating characteristics (ROC) curve, with infectious complications as an outcome measure. ROC curves with the largest area under the curve for each inflammatory marker were compared in order to define the marker with higher diagnostic accuracy. RESULTS: Twenty nine patients (36.7%) developed infectious complications. CRP and PCT concentrations increased in the early postoperative period, with a significant difference between patients with and without complications at all measured postoperative times. ROC curve analysis showed that CRP concentrations on POD 3 and PCT concentrations on POD 2 had similar predictive values for the development of infectious complications (area under the curve, 0.746 and 0.750, respectively) with the best cut-off values of 99.0 mg/L for CRP and 1.34 µg/L for PCT. Diagnostic accuracy of CRP and PCT was highest on POD 5, however the cut-off values were not considered clinically useful. CONCLUSION: Serial postoperative PCT measurements do not offer an advantage over CRP measurements for prediction of infectious complications following colorectal surgery.