Operative vaginal deliveries and their impact on maternal and neonatal outcomes - prospective analysis.

OBJECTIVE: Evaluation of maternal and neonatal outcomes in operative vaginal deliveries in prospective study analysis. DESIGN: Prospective case-control study analysis. SETTING: Prospective analysis of 292 operative vaginal deliveries (VEX, forceps) for the period June 2016 - August 2017 from overall 6056 vaginal deliveries. Type and frequency of maternal and neonatal trauma occurence was observed in connection with using vacuum-assisted delivery and forceps delivery, mainly the cephalohematomas and their complications. Collected data were statistically analysed. RESULTS: In the reported period from overall 6056 deliveries there were 216 vacuumextractions (3.6%) and 72 forceps deliveries (1.2%) performed. Both methods were used in four patients (VEX and forceps). The most frequent trauma in newborns were cephalohematomas. Remarkable cephalohematoma, requiring further observation has occured in 40 newborns (18.5%) after vacuum-assisted delivery and in 5 newborns (6.9%), (p = 0,017) after forceps delivery. Consequential punction of cephalohematoma occured only after vacuumextraction delivery and in 6 newborns (15.0 %). The third degree perineal rupture occured after vacuumextraction in 20 patients (9.3%) and after forceps delivery in 12 patients (16.7%), (p = 0,091). The fourth degree perineal rupture occured only after vacuumextraction and in 1 case (0.5%). CONCLUSION: The vacuumextraction compared with forceps is more likely to be associated with the statistically significant incidence of cephalohematomas and their further treatment. Forceps deliveries compared with vacuumextraction are more likely to be associated with the maternal perineal trauma, but the diference was not statistically significant.

Uterine rupture during pregnancy and delivery: risk factors, symptoms and maternal and neonatal outcomes - restrospective cohort.

OBJECTIVE: To analyze cases of uterine rupture during pregnancy and delivery. To report risk factors, maternal and neonatal outcomes. DESIGN: Restrospective cohort study. SETTING: Department of Obstetrics and Gynecology, Masaryk University, University Hospital Brno. METHODS: This study used data from medical records of 36 195 labours between 2011-2016 in the Department of Obstetrics and Gynecology Masaryk University Hospital Brno. We identified all cases of complete and incomplete uterine rupture diagnosed during pregnancy, delivery and puerperium. We analyzed risk factors, symptoms and signs and maternal and neonatal outcomes. RESULTS: We identified 15 uterine ruptures. Three cases occurred during pregnancy in absence of labour, ten cases in association with delivery, one case during puerperium and one case of uterine rupture was associated with induction of abortion in the 2nd trimester. Eight patients had a previous cesarean section. Other uterine surgery was reported in history of four cases, including myomectomy, perforation of uterine fundus during hysteroscopy, curretage. Three patients had unscarred uterus. Most of the cases presented with abnormal fetal heart rate tracing, abdominal pain, vaginal bleeding and hypotension. There were two perinatal deaths associated with uterine rupture and perinatal asphyxia was observed in five infants. No mother died in association with uterine rupture. Estimated blood loss higher than 1000 ml occurred in 11 cases. Three patients underwent hysterectomy. CONCLUSION: Overall prevalence of uterine rupture during pregnancy and delivery was 0,04%, in women with previous cesarean section was 0.2%, in women with unscarred uterus was 0.08. Suspicious fetal heart rate tracing and acute abdominal pain are the most common symptoms. Adverse neonatal outcomes were identified in seven cases.

Management of Medical Termination of Pregnancy (MToP) up until the 7th week of gestation in the Czech Republic.

OBJECTIVE: In the Czech Republic (CR), it is possible, to carry out Medical Termination of Pregnancy (MToP) in the 1st trimester since June 2014, in case a woman submits a written request for it and in case the ultrasound examination confirms an intrauterine singleton prosperous pregnancy, between day 42 and 49 of gestation, crown-rump length (CRL) of the embryo 2-9 mm. The aim of the study is to analyze the management of MToP up until the 7th week of gestation in five centres in the CR. DESIGN: Multicenter cohort (prospective) study. SETTING: Department of Obstetrics and Gynecology, Palacky University Olomouc, Faculty of Medicine and Dentistry, University Hospital Olomouc; The Institute for the Care of Mother and Child, Charles University in Prague, Third faculty of Medicine; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, General University Hospital in Prague; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, Hospital Na Bulovce, Prague; Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine, University Hospital Brno. METHODS: In 2014-2016, a total of 1820 pregnant women requested MToP. The diagnosis of an intrauterine singleton prosperous pregnancy was set by transvaginal ultrasound, CRL 2-9 mm. MToP was carried out by combination of mifepristone (600 mg orally) and misoprostol (400 mcg orally) within 48 hours. MToP follow up (exclusion of ongoing pregnancy) after 2-3 weeks was carried out by transvaginal ultrasound as well. RESULTS: In 11.0% of women (201/1820) who requested MToP, CRL > 9 mm, unprosperous, multiple or ectopic pregnancy was diagnosed. In the remaining 1619 women MToP was carried out, but in 221 cases (13.7%) at least one additional pre-first visit was needed before the diagnosis of intrauterine singleton prosperous pregnancy CRL 2-9 mm could be established, in 19 cases (1.2%) two pre-first visits and in 5 cases (0.3%) even three. Gestational age was 42-49 days (average 47.1, median 47), the women were 14-47 years of age (average 30.7, median 30). In 20.8% of women (336/1619) MToP follow up was missed and of the remaining 1283 women, ongoing pregnancy (MToP failure) was diagnosed in 1.6% (24/1283), incomplete abortion in 6.5% (83/1283) and complete abortion in 91.9% (1179/1283). A subsequent surgical intervention was carried out in 7.1 % of women (91/1283). CONCLUSION: A medical facility performing MToP in the 1st trimester should develop its own methodology in accordance with the legislation in force, Summaries of Product Characteristics, and recommendations of professional associations. The methodology should also include a method of evaluation of the result and management. The subsequent surgical intervention should only be performed in indicated cases. The main goal of MToP follow up is to exclude ongoing pregnancy (MToP failure), and the patient should be informed in detail about the risks involved and possibilities of their solution, it is necessary to obtain an informed consent.

[Management of Medical Termination of Pregnancy (MToP) up until the 7th week of gestation in the Czech Republic]. / Management umelého ukoncení tehotenství Farmakologickou metodou, nepresahuje-li tehotenství 7 týdnu, v Ceské republice.

OBJECTIVE: In the Czech Republic (CR), it is possible, to carry out Medical Termination of Pregnancy (MToP) in the 1st trimester since June 2014, in case a woman submits a written request for it and in case the ultrasound examination confirms an intrauterine singleton prosperous pregnancy, between day 42 and 49 of gestation, crown-rump length (CRL) of the embryo 2-9 mm. The aim of the study is to analyze the management of MToP up until the 7th week of gestation in five centres in the CR. DESIGN: Multicenter cohort (prospective) study. SETTING: Department of Obstetrics and Gynecology, Palacky University Olomouc, Faculty of Medicine and Dentistry, University Hospital Olomouc; The Institute for the Care of Mother and Child, Charles University in Prague, Third faculty of Medicine; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, General University Hospital in Prague; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, Hospital Na Bulovce, Prague; Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine, University Hospital Brno. METHODS: In 2014-2016, a total of 1820 pregnant women requested MToP. The diagnosis of an intrauterine singleton prosperous pregnancy was set by transvaginal ultrasound, CRL 2-9 mm. MToP was carried out by combination of mifepristone (600 mg orally) and misoprostol (400 mcg orally) within 48 hours. MToP follow up (exclusion of ongoing pregnancy) after 2-3 weeks was carried out by transvaginal ultrasound as well. RESULTS: In 11.0% of women (201/1820) who requested MToP, CRL > 9 mm, unprosperous, multiple or ectopic pregnancy was diagnosed. In the remaining 1619 women MToP was carried out, but in 221 cases (13.7%) at least one additional pre-first visit was needed before the diagnosis of intrauterine singleton prosperous pregnancy CRL 2-9 mm could be established, in 19 cases (1.2%) two pre-first visits and in 5 cases (0.3%) even three. Gestational age was 42-49 days (average 47.1, median 47), the women were 14-47 years of age (average 30.7, median 30). In 20.8% of women (336/1619) MToP follow up was missed and of the remaining 1283 women, ongoing pregnancy (MToP failure) was diagnosed in 1.6% (24/1283), incomplete abortion in 6.5% (83/1283) and complete abortion in 91.9% (1179/1283). A subsequent surgical intervention was carried out in 7.1 % of women (91/1283). CONCLUSION: A medical facility performing MToP in the 1st trimester should develop its own methodology in accordance with the legislation in force, Summaries of Product Characteristics, and recommendations of professional associations. The methodology should also include a method of evaluation of the result and management. The subsequent surgical intervention should only be performed in indicated cases. The main goal of MToP follow up is to exclude ongoing pregnancy (MToP failure), and the patient should be informed in detail about the risks involved and possibilities of their solution, it is necessary to obtain an informed consent.

[External cephalic version of breech fetus after 36 weeks of gestation - evaluation of efectiveness and complications]. / Obrat plodu zevními hmaty z polohy podélné koncem pánevním po 36. týdnu gravidity - hodnocení úspesnosti a komplikací.

OBJECTIVE: Evaluation of success rate and the safety of external cephalic version after 36 weeks of gestation. DESIGN: Retrospective analysis. SETTING: Department of Obstetrics and Gynecology, Masaryk University, University Hospital Brno. METHODS: A retrospective analysis of external cephalic version attempts performed on a group of 638 singleton breech pregnancies after 36 weeks gestation in the years 2003-2016 at the Department of Gynecology and Obstetrics, Masaryk University, Brno. The effectiveness, number and type of complications, mode of delivery and perinatal result were observed. RESULTS: The effectiveness of external cephalic version from breech to head presentation was 47.8% (305 cases). After a successful external cephalic version 238 patients (78.0%) gave birth vaginally. After unsuccessful cephalic version 130 patients (39.0%) gave birth vaginally. The number of serious complications did not exceed 0,9% and did not affect perinatal outcomes. External cephalic version-related emergency cesarean deliveries occurred in 6 cases (2 placental abruption, 4 abnormal cardiotocography). The fetal outcome was good in all these cases. The death of the fetus in connection with the external version has not occurred in our file. Spontaneous discharge of amniotic fluid within 24 hours after procedure occurred in 5 cases (0.8%). The spontaneous onset of labor within 24 hours of procedure occurred in 5 cases (0.8%). The pH value of a. umbilicalis < 7.00 occurred in 2 cases in the group with a successful external version and in the group with unsuccessful external version in 9 cases. The Apgar score in the 5th minute < 5 was both in the successful and unsuccessful group in 1 case. CONCLUSION: The external cephalic version of the fetus in the case of breech presentation after the 36th week of pregnancy is an effective and safe alternative for women who have a fear of the vaginal breech delivery. Performing the external cephalic version can reduce the rate of elective caesarean sections due to breech presentation at term.

[Specific placental complications of monochorionic diamniotic twins born after 24 weeks of pregnancies - restrospective analysis]. / Specifické placentární komplikace u monochoriálních biamniálních dvojcat porozených po 24. týdnu gravidity - retrospektivní analýza.

OBJECTIVE: Purpose of this study was to determine the frequency of occurence of specific complications of monochorionic diamniotic twins born after 24 weeks of pregnancies and the effect of these complications on perinatal morbidity and mortality. TYPE OF STUDY: Restrospective analysis. SETTING: Dpt. of Obstetrics and Gynecology Masaryk University and University Hospital Brno. METHODOLOGY: A retrospective analysis of 175 monochorionic diamniotic pregnancies (mo-bi), which were terminated after the 24th week of pregnancy at the Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno between the years 2008-2013. The specific complications such as twin-to-twin syndrome (TTTs), twin anemia polycytemia sequens (TAPS), selective intrauterine growth restriction (sIUGR), twin-arterial revers perfusion sequence (TRAP), single intrauterine fetal death (IUFD), placental insufficiency with both twins were identified using prenatal ultrasound examinations, perinatal results and the result of pathological anatomical examinations. Perinatal morbidity, neonatal mortality and neurological development were evaluated. The numbers of late detections of specific complications were observed. RESULTS: Specific complications in our group were identified in 50 pregnancies (28.6%). TTTs was diagnosed most often, by 18 pregnancies (10.3%), next most frequent diagnosis were sIUGR (9.7%) and TAPS (3.4%). The placental insufficiency with both twins complicated 2.6% pregnancies. 10 children had abnormal neurological development. Pregnancies with late detection had the worst perinatal results. No acute TTTs during delivery was detected. CONCLUSION: Specific placental complication reached 29.7% in our file. The most frequent complication was TTTs (10.3%) and selective growth restriction (9.7%). Pregnancies with late diagnosis of these complications had the worst results. The prenatal care by monochorial biamnial pregnancies should be at specialized centres from the 16th week of pregnancy every two weeks.

[Medical termination of pregnancy by mifepristone and misoprostol - evaluation of succes rate, complications and satisfaction of patients]. / Farmakologické ukoncení gravidity mifepristonem a misoprostolem - zhodnocení úspesnosti, komplikací a spokojenosti pacientek.

OBJECTIVE: The purpose of this study was to evaluate the success rate and complications of medical termination of pregnancy up to 49 days of amenorrhea and present the outcome of our phone questionaire of satisfaction of patients. DESIGN: Retrospective analysis. SETTING: Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno. METHODS: The analysis of 111 patients, who underwent medical termination of pregnancy at the Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno from 1. 6. 2014 to 30. 6. 2015 using 600 mg of mifepristone (Mifegyne) and 400 µg of misoprostol (Mispregnol). In our set of patients we monitored subjective perception of medical termination of pregnancy (pain, nausea, vomiting, satisfaction with this method) and objective process (hospitalisation, surgical intervention). The view of patients was found out by the phone questionnaire RESULTS: Complete abortion without a surgical intervention underwent 103 patients. Nausea, pelvic pain, and intensity of bleeding were evaluated as suitable. Only 1 patient (0.9%) was hospitalised for nausea and 1 patient (0.9%) was hospitalised in case of need for an emergency curretage and transfusions. Some kind of contraception after the medical termination of pregnancy started using 98.0% of women. The satisfaction rate of this method was high - 101 patients declared themselves satisfied - 66.7% very satisfied, 24.3% rather satisfied. CONCLUSION: Medical termination of pregnancy has good efficiency, we consider it safe with minimum side-effects and is well evaluated by patients.

[Pregnancy and delivery in patients with an implanted shunt for hydrocephalus]. / Gravidita a porod u pacientek s implantovaným shuntem pro hydrocefalus.

UNLABELLED: Hydrocephalus is a disorder of abnormal accumulation of cerebrospinal fluid in the intracranial space, usually in the cerebral ventricles. The number of patients reaching reproductive age and intending to become pregnant has increased in recent years because of treatment advances. An implanted shunt is usually introduced into the abdominal cavity (ventriculoperitoneal shunt). Numerous changes occur during pregnancy, mainly increased accumulation of water, increased intracranial cerebrospinal fluid volume and increased intra-abdominal pressure as a result of the growing uterus. These changes contribute to increased incidence of complications during pregnancy and childbirth. Therefore, it is necessary to make a preconception exam and specify pregnancy management, a suitable method of childbirth and dealing with potential complications. Multidisciplinary care is mandatory with the dominant cooperation of obstetricians and neurosurgeons who should be also available during the delivery when needed. Possible shunt malfunction is necessary to diagnose properly and in time and solve it individually, taking into account the overall and neurological status of the patient and gestational age. The presence of a shunt does not affect pregnancy and vaginal delivery is considered by most authors as the first option. Primary cesarean section is preffered in patients with obstructive hydrocephalus or rapid deterioration in the case of shunt malfunction. Epidural anesthesia or general, eventually spinal anesthesia are recommended. KEYWORDS: hydrocephalus, shunt, ventriculoperitoneal shunt, ventriculoatrial shunt, endoscopy, endoscopic third ventriculostomy, pregnancy.

[Incarcerated uterus in pregnancy - pitfalls of diagnosis, clinical course and therapy: two case reports]. / Inkarcerace delohy v gravidite - úskalí diagnostiky, klinického prubehu a terapie: dve kazuistiky.

OBJECTIVE: Analysis of two cases of incarcerated uterus during pregnancy. DESIGN: Two case reports. SETTING: Department of Gynecology and Obstetrics, Masaryk University, University Hospital Brno. METHODS AND RESULTS: In two cases of incarcerated uterus, which were resolved on Department of Gynaecology and Obstetrics, University Hospital Brno is shown a different clinical course, leading to the detection and solutions at different gestational weeks. The first case was detected in 31st week of pregnancy and was characterized by nearly asymptomatic course in a pregnant woman with a scar in the lower uterine segment after a previous caesarean section. The delivery was scheduled for the end of the 36th week of pregnancy by iterative caesarean section. The second case was detected on the 27th week of pregnancy due to significant subjective difficulties of pregnant woman that impressed as acute event of abdomen. Despite all attempts at conservative therapy was necessary to terminate the pregnancy by caesarean section at 28 week of pregnancy due to the high risk of uterine rupture. CONCLUSION: Incarcerated uterus is a rare complication of pregnancy. Diagnostics complains varied clinical picture of the nonspecific subjective difficulties. Missed diagnosis can lead to a number of serious obstetric complications. In case of failure of conservative therapy and progression of difficulties is necessary to think about the real risk of uterine rupture. Before performing a caesarean section is essential knowledge of the mutual position of the lower uterine segment, urinary bladder and cervix.

[Vaginal birth after previous caesarian section--outcomes analysis 2007-2010]. / Vedení porodu po predchozím císarském rezu, analýza výsledku z let 2007-2010.

OBJECTIVE: Analysis of births after previous caesarean section (SC) at Department of Obstetrics and Gynaecology, Masaryk University, Brno. Determination of successful vaginal deliveries after previous SC (complete vaginal birth) and the factors that influence success. Risk identification and determination of the frequency of complications. Comparison of vaginal births after previous SC (VBAC) with elective repeat caesarean section (ERCS). MATERIALS AND METHODS: Retrospective analysis of 24,342 births, which were conducted in 2007-2010 at Department of Obstetrics and Gynaecology, Masaryk University, Brno. For the reporting period a total of 1391 pregnant women with a history of caesarean section gave birth (100.0%). The distribution of births after previous caesarean section into 2 groups according to a method of delivery. Trying to line vaginal birth (VBAC) with 986 mothers (70.9%). Elective repeat caesarean section (ERCS) was performed in 405 mothers (29.1%). Analysis and comparison of results in both groups. RESULTS: The overall success of VBAC (complete vaginal births after previous SC) in our group reached 80.8%. When evaluating the success of the subgroups was the strongest positive predictive factor the onset of spontaneous contractile activity (89.5% success rate) and vaginal delivery in history (88.2% success rate). The most significant negative predictive factor was a history of previous caesarean birth because of failure mechanism of birth (success rate 72.0%). The most common complication in both groups VBAC and ERCS group was blood loss (5.1% versus 2.0%, p = 0.045). Detection of dehiscence at the previous uterotomy (0.4% versus 0.5%, NS). In our group has been reported no case of uterine rupture. The frequency of postpartum hysterectomy was comparable in both groups (0.3% versus 0.5%, NS). In both groups, VBAC and ERCS was reported one case of bladder lesion, as surgical complications during the acute or planned caesarean section. No maternal or fetal death in relation to birth in our cohort occurred. CONCLUSION: Vaginal birth after previous caesarean section is a safe way of delivery in selected groups of mothers. An essential requirement is careful monitoring during labor to the exclusion of excessive uterine activity and protracted labor.

[Insertion-deletion polymorphism in the gene for angiotensin-converning enzyme (I/D ACE) in pregnant women with gestational diabetes]. / Inzercne-delecní polymorfismus v genu pro angiotensin-konvertující enzym (I/D ACE) u tehotných s gestacním diabetem.

AIM OF THE STUDY: The aim of the study was to investigate possible associations of the Angiotensin-converting enzyme insertion/deletion (I/D ACE) polymorphism with gestational diabetes mellitus occurrence. METHODS: Number of 53 healthy pregnant women (controls) and 48 women with gestational diabetes mellitus were included in the study. The woman patients were hospitalised in the Clinic of Obstetrics and Gynaecology, Masaryk University Affiliated hospital Brno during the period 10/2004 - 10/2005. In all cases there was the spontaneous one baby pregnancy. The procedure was obtaining the peripheral blood samples from women of those two groups and isolation of their DNA using standard technique with the use of proteinase K. I/D ACE genotype of each person was determined using allele specific primers. RESULTS: We did not prove significant association neither of the genotype distribution (P(g)) P(g) = 0.115 nor allele frequency (P(a)) P(a) = 0.873 between controls and women with gestational diabetes mellitus. The significant differences of genotype distributions (P(g) = 0.03) were observed in women with two and more labours in anamnesis. Borderline significant differences of genotype distributions (P(g) = 0.08) were found in women with one and more abortions in anamnesis. CONCLUSIONS: According to our results the variability in ACE gene can be taken as factor contributing to manifestation of gestational diabetes mellitus. According to results of our study I/D ACE polymorphism can't be taken as genetic marker of gestational diabetes mellitus.

Non-invasive fetal RHD and RHCE genotyping from maternal plasma in alloimmunized pregnancies.

BACKGROUND: In this prospective study, we assessed the feasibility of fetal RH genotyping by analysis of DNA extracted from maternal plasma samples of alloimmunized pregnant women using real-time PCR and primers and probes targeted toward RHD (exon 7 and exon 10) and RHCE (intron 2 and exon 5) genes. METHODS: We analysed 23 alloimmunized pregnant women (16 anti-D, 5 anti-D + C, 2 anti-E) at risk of haemolytic disease of the newborn (HDN) within 11th and 37th week of pregnancy and correlated the results with serological analysis of cord blood. RESULTS AND CONCLUSION: Detection of the presence of the RHD gene, the C and/or E alleles of the RHCE gene in maternal plasma samples is highly accurate and enables implementation in a clinical diagnostic algorithm for following pregnancies at risk for HDN. The absence of RHD gene, the C and/or E alleles of RHCE gene in the current pregnancy excludes the risk of HDN caused by anti-D, anti-C and/or anti-E alloantibodies and the performance of invasive fetal-blood sampling.