Diastolic deceleration area in the fetal MCA: a new Doppler parameter.

Objective: Doppler velocimetry has been widely used throughout the years as a valuable tool in the follow-up and prognosis of various pregnancy complications. Numerous Doppler indices have been introduced to qualitatively describe fetal blood flow. Currently, the Pulsatility index (PI) is the most widely used index for this purpose. In current clinical practice, middle cerebral artery (MCA) PI measurement is commonly used to assess fetal well-being, especially in late-onset fetal growth restriction (FGR). However, existing evidence suggests that MCA PI alone is inferior to the ratio between MCA and umbilical artery (UA) pulsatility indices in predicting adverse perinatal and neonatal outcomes. When comparing normal and abnormal MCA Doppler waveforms, it is evident that most changes appear in the diastolic part of the heart cycle. Therefore, the PI, which contains elements from both systole (peak systolic velocity-PSV) and diastole (end-diastolic velocity), may not be the most effective tool for quantifying fetal brain sparing (BS).Methods: We hypothesize that another measurement modality that focuses predominantly on the diastole could be more efficient for evaluating the amount of vasodilatation. In ultrasound velocimetry of larger blood vessels, there is a well-known phenomenon called "dicrotic notch" (DN), which appears on the declining part of each Doppler waveform and can be used to precisely pinpoint the end of systole and the start of diastole. We hypothesized that the extent of cerebral vasodilation can be more accurately assessed by measuring the area between the dicrotic notch (DN) and the end-diastolic velocity (which we refer to as the "diastolic deceleration area-DDA"). In this study, we introduced a new Doppler parameter along with a rationale for DDA measurement in the fetal MCA. We also defined third-trimester nomograms and provided a preliminary assessment of the correlation between DDA and fetal oxygen deficiency.Results: Our findings suggest that the DDA may serve as an independent instrument for identifying hypoxia during late pregnancy, either on its own or in conjunction with other Doppler and cardiotocography modalities.Conclusion: However, before incorporating DDA into clinical practice, it is crucial to conduct further research and validation studies with larger sample sizes and more diverse populations. This would help assess the generalizability of the results and establish optimal cutoff points for DDA in various clinical settings. It is also important to prospectively study the role of DDA in early- and late-onset fetal growth restriction (FGR), Rh-isoimmunization/anemia, preeclampsia, gestational diabetes, and other pregnancy complications. In fact, we believe that the concept of measuring specific areas in arterial Doppler velocimetry indices could have significant implications not only in fetal medicine and obstetrics, but also in other areas of human and veterinary medicine.

[INFLUENCE OF DIANATALO OBSTETRIC GEL ON THE LENGTH OF SECOND STAGE OF LABOR.]

One of the risk factors for the occurrence of occult anal sphincter injuries (OASIS) and pelvic floordamage is the increased duration of the second stage of labor; leading to a relatively high incidence of perineal trauma, which in the majority of cases remains unrecognized. If we can decrease the duration of second stage of labor we could also expect a statistically significant decrease the incidence of OASIS in clinical practice. Purpose and Goals To identify changes in the length of the second slage of labor fater adminidtration of Dianatal® obstetric gel. Material and methods The study enrolled 33 primiparous women after vaginal delivery in General Hospital Trbovlje, Slovenia between January and June 2012. We also included 19 more patients, delivered between May and July 2011 in the Department of Obstetrics, University Hospital - Pleven, and 8 patients, delivered between February and October 2013 in Women's Health Hospital "Nadezhda" - Sofia Results We were able to observe a significant decrease in second slage of labor in relation with administration of Dianatal® obstetric gel. Discussion Shortening the period of expulsion of the fetus through the use of obstetric gel can significantly reduce the incidence of birth trauma and minimize complications related to delivery trauma - anal and urinary incontinence, changes in the statics of pelvic organs, sexual dysfunction and as a result poor quality of life.

[EVALUATION OF INCIDENCE OF POSTPARTUM OCCULT ANAL SPHINCTER INJURIES BY ENDOANAL ULTRASONOGRAPHY.]

The estimated overall risk of intrapartum damage of the anal sphincter (IUAS) is 1% of all vaginal births. The so called "occult" anal sphincter injuries (defects of the anal sphincter established by endoanal ultrasonography - OASIS) occur in 33% of primiparous women after vaginal birth. The most logical explanation for OASIS is that they are either completely missed or detected, but not mentioned in the patient's documentation, or erroneously classified as a low grade tear. Objectives To es7ablish the actual values of OASIS in the study population using endoanal ultrasonography. Material and methods The study included 29 vaginal deliveries in Porodnisnica Ljubljana in the January to June 2009 period, and 34 patients from July 2009 to May 2010, who gave birth in ObsTetric Clinic of the University Hospital - Pleven. Results The identified UAS frequency in our dtudy (25.4%) confirms the results of the incidence of such damage, cited in the literature. Discussion The results vary extensively from reported frequency of anal sphincter injuries among researched population, reflecting underesTimation of the problem, diagnostic gaps and inadequate clinical management behavior and tracking patients.

[RISK FACTORS FOR POSTPARTUM OCCULT INJURIES OF THE ANAL SPHINCTER.]

introduction The overall risk of intrapartum damage the anal sphincter (IUAS) is 1% of all vaginal births. In contrast, the so-called "occult" anal sphincter injuries (OASIS) (defects esablished by endoanal ultrasonography) occur in 33% of primiparous women after vaginal birth. Identifying the most common risk factors for OASIS can be the basis for selecting high-risk patients. These women should be targeted by early pospartum diagnosis and treatment, which could reduce the incidence of anal incontinence developed later in life. Objectives To determine the role of common risk factors for the occurrence of OASIS in selected population. Material and methods The study included 42 patients after vaginal birth, born in Maternity Ljubljana in the period January to June 2009, and 38 patients from July 2009 to November 2011, born in Obstetric Clinic of the University Hospital - Pleven, diagnosed with OASIS using endoanal ultrasonography. Results We demonstrated that all of the independent variables studied in our research (primiparity, gestational age over 41gw and fetal weight over 3500 g.) are risk factors for the occurrence of OASIS. Discussion This sudy shows that the sudied risk factors for the occurrence of OASIS may be included in a clinical practice guideline for eady diagnosis and proper treatment of posTpartal injuries affecting the pelvic floor.

[Indirect standard cardiotocography plus fetal blood sampling versus indirect quantitative cardiotocography--a randomized comparative study in intrapartum monitoring].

INTRODUCTION: In previous papers we proposed ways to improve the diagnostic potential of the "quantitative cardiotocography" computer method, which allowed us to introduce clinical practice guidelines. Using these guidelines we aim to evaluate the effectiveness of quantitative cardiotocography (qCTG) as compared to standard cardiotocography (CTG) and, if necessary fetal blood sampling (FBS). MATERIAL AND METHODS: The prospective study involves 220 pregnant women divided randomly into two groups. All 110 women in the control group were monitored by standard indirect cardiotocography Interpretation of CTG findings was performed according to the latest revision of FIGO classification. We performed FBS in all cases of abnormal or suspect CTG tracings and pH values below 7.20 were indicative for urgent delivery. If pH values were in the range between 7.20 and 7.25, another FBS was carried out after 30 minutes. If pH was above 7.25, FBS was repeated according to CTG evaluation by the attending doctor. All patients in the index group (110 women) were monitored by indirect quantitative cardiotocography (qCTG). Our clinical practice guidelines were used for the interpretation of CTG tracings. Obstetric behavior was strictly based on the recommendations in these guidelines. Outcome measures are: incidence of metabolic acidosis (defined by pH < 7.05 and BE > -12 mmol/l in the umbilical cord artery of the newborn), number of instrumental deliveries and sensitivity/specificity of each method (qCTG and CTG + FBS) in relation to fetal hypoxia (defined by pH < 7.20). RESULTS: In the CTG group, 4.4% of the newborns were affected by metabolic acidosisas opposed to 2.2% in the qCTG group (P > 0.05). The sensitivity/specificity rates for fetal hypoxia were 89/67% (control group) and 97/85% (index group). The number of operative deliveries was 27.25% and 16.35%, respectively (P < 0.05). CONCLUSION: The incidence of metabolic acidosis was comparable in both groups. Indirect quantitative cardiotocography shows much better specificity for fetal hypoxia which results in significantly lower rates of operative deliveries compared to standard indirect cardiotocography combined with fetal blood sampling.

[Structure and function of the cardiotocographic score (CTG-score) calculated by the "quantitative cardiotocography" computer method. Determining the significance of its components for the accuracy of the estimates for the ph of the fetus].

INTRODUCTION: In the last three years "quantitative cardiotocography" has become the main method for fetal monitoring during late pregnancy and birth in Sheynovo hospital - Sofia, Bulgaria. Our previous studies presented opportunities for increasing the diagnostic potential of the methodology. In this paper we offer a new approach to further improve the accuracy of prognostic values for fetal pH during labor. This is achieved by analyzing the individual components of the CTG-score (microfluctuation - OSZ, basic fetal heart rate - FRQ and decelerations - DEC). Several groups of CTG-scores have been formed, according to the composition of the score and the correlation between forecast and actual results for the pH of the fetus. MATERIAL AND METHODS: For each of the stored 171 recordings we compared the CTG-score, produced prior to the delivery, with the pH measured in the umbilical artery (UA) before cutting the umbilical cord. As fetal pH forecast is based strictly on the CTG-score value, the difference between actual and prognostic results for the pH actually shows how accurate is the CTG score itself. We used standard deviation (Std. deviation) to assess this variability. RESULTS: We defined several groups of CTG-score based on its composition and the respective standard deviations. Each group includes CTG-scores with no significant statistical difference between the calculated standard deviations: CTG-score with low (composed of OSZ; Std. Dev. 0.065), satisfactory (composed of OSZ + FRQ and FRQ; Std. dev 0048 and 0044), high (composed of OSZ + DEC and DEC; Std. dev 0032 and 0027) and very high (composed of FRQ + DEC and OSZ + FRQ + DEC; Std. dev. 0019 and 0012) predictive value. We observed a substantial variety in the prognostic results, depending on which components of the CTG-score are involved in the evaluation of pH. CONCLUSION: The composition of the CTG-score seems to be crucial for the accuracy of the prognostic fetal pH values. In order to organize the gathered information it is necessary to develop clinical practice guidelines which would allow us to cohere the obstetric behavior with data readings from the quantitative cardiotocography method.

["Quantitative cardiotocography"--clinical practice guideline].

INTRODUCTION: The "quantitative cardiotocography" method provides important information about the condition of the fetus during labor, non-invasively and in real time. Since the forecast pH-results are being updated every 5 (five) minutes, significant differences in the readings for pH can be observed. In certain cases this can hamper the evaluation of fetal condition and lead to contradictions. Such inconveniences can be easily avoided by using the arithmetic average value of the last 6 forecast results for pH, generated by the quantitative cardiotocography software. Another inconvenience of the "quantitative cardiotocography" method lies in the fact that the components involved in the formation of CTG-score seem to be unequal in terms of potential for evaluating the fetal condition. Based on that, we believe that clinical practice guideline is needed. We developed such guideline based on two main criteria: the arithmetic average value over the last 6 (six) pH estimates; which components of the CTG-score are involved in the formation of the pH forecast readings. MATERIAL AND METHODS: Our previous studies demonstrated that in 85% of all cases, the actual pH value of the newborn was in the range of -0037/+0046 from the average arithmetic value of the last six (6) pH estimates before the delivery. Based on this variability in the pH forecast results we defined three groups of findings--normal (pH 7.350 to 7.237), suspect (pH of 7.237 to 7.137) and abnormal (pH < 7.137). In another study, we differentiated several varieties of CTG-score (with very high, high, satisfactory and low predictive value), depending on the observed deviations between forecast and actual pH results. RESULTS: pH forecast results should always be assessed together with the composition of the CTG-score. This can be achieved by using the presented clinical guideline, which also contains recommendations for adopting specific obstetric behavior, based on the "quantitative cardiotocography" readings. CONCLUSION: In future studies we will investigate if it is possible the presented clinical practice guideline to replace fetal blood sampling for intrapartal assessment of the fetal condition. Further clinical studies will clarify whether the use of this clinical guideline could lead to a reduction in the incidence of metabolic acidosis in newborns or change the percentage of operative deliveries compared with the cases where classical indirect cardiotocography was used.

[A comparative study of the prognostic pH values of the fetus in utero, generated by the "quantitative cardiotocography" computer method, and the actual pH values measured immediately after delivery].

INTRODUCTION: The presented methodology for quantitative evaluation of the cardiotocographic (CTG) findings unconditionally provides essential opportunities for improving the diagnostic potential in modern obstetric practice. Current literature data concerning the clinical application of this method are scarce. Credible clinical trials are needed to determine what is the correlation between estimated and actual values of the studied variables. MATERIALS AND METHODS: A prospective study on 110 pregnant women was performed. All patients were monitored via indirect cardiotocography. The recordings were stored and analyzed by the computerized method for "quantitative cardiotocography". We compared the last prognostic fetal pH value, generated by the "quantitative cardiotocography" software during labor, with the actual pH measured from the umbilical artery (UA) of the newborn. RESULTS: For each of the stored CTG recordings we quantified the difference between the last forecast and the actual pH of the newborn. In 82% of these cases this difference was in range of -0081/+0074 from the projected results. However during the study we discovered that there is a significantly better correlation between the arithmetic average of the last 6 (six) predicted results and the actual pH of the newborn. In 85% of these cases the difference between forecast and actual pH values lies a in range of -0037/+0046. CONCLUSION: Using the arithmetic average of the last 6 (six) predicted results for pH leads to a significant increase in the clinical value of the "quantitative cardiotocography". More studied are needed if we are to find opportunities to further reduce the existing prediction variability.

[Quantitative cardiotocography].

UNLABELLED: Cardiotocography (CTG) is an up-to-date practical method for fetal surveillance during pregnancy and labor. More precise reading of the CTG data is possible with the use of some fetal acid-base parameters, taken from the umbilical artery (UA). Unfortunately, invasive procedures like fetal scalp blood sampling and/or cordocentesis are required to obtain these results. Latest computer technology enables us to create mathematical algorithms that uninvasively calculate prognostic values for fetal blood pH, based on interpretation of key CTG features. The method is called "Quantitative cardiotocography" and is implemented in a software solution for fetal surveillance in 2007. In this study the authors present their first clinical results using the method, which they recently introduced for the first time in Bulgaria. A total of 1356 CTG recordings with pH prediction were stored and analysed. These findings have been carefully taken into consideration in the context of some clinical conditions like preeclampsia, pre- and post-term delivery placental abruption, etc. Early results are showing fairly good correlation between computer-analysed abnormal CTG findings and presence of the above mentioned clinical conditions. CONCLUSIONS: Quantitative appraisal of CTG findings and acid-base parameters leads to much more precise interpretation of the CTG phenomena, which guarantees higher quality of fetal surveillance during pregnancy and labor.

Escherichia coli inorganic pyrophosphatase: site-directed mutagenesis of the metal binding sites.

Aspartic acids 65, 67, 70, 97 and 102 in the inorganic pyrophosphatase of Escherichia coli, identified as evolutionarily conserved residues of the active site, have been replaced by asparagine. Each mutation was found to decrease the k(app) value by approx. 2-3 orders of magnitude. At the same time, the Km values changed only slightly. Only minor changes take place in the pK values of the residues essential for both substrate binding and catalysis. All mutant variants have practically the same affinity to Mg2+ as the wild-type pyrophosphatase.

[Antibiotic prevention and treatment in cesarean section]. / Antibiotichna profilaktika i lechenie pri sectio caesarea.

The aim of the authors ia to study the role of antibiotic prophylaxis in cesarean section for prevention of infectious complications during puerperium. 443 deliveries were studied, which took place by cesarean section at the obstetric clinic of the Higher Medical Institute in the town of Pleven for a 2-year period. One antibiotic was administered in 96 women (21.67%) up to the third day, but in 62 women--up to the sixth day (14.00%). Two antibiotics were used is 49 parturients (11.06%) up to the third day, but in 131 women (29.57%) up to the sixth day. The combination of 3 antibiotics, containing a preparation against anaerobic infection, was used in 43 women (9.7%). The most frequent complication--endometritis was observed in 17 of operated women (3.84%), but suppuration of the operative wound--in 8 women (1.81%). After a 6-day prophylaxis with penicillin and gentamycin the frequency of endometritis was higher than that with ampicillin and gentamycin (11.76% against 2.60%). An impression was created that there was not a single case with endometritis and only one case with suppuration among 62 (13.99%) women operated without usage of antibiotics as well as in 145 (32.73%) women with antibiotic therapy up to the third day. All these parturients were with low risk of puerperal infection. Our position is that they do not need antibiotic prophylaxis.

[Diagnostic problems in extrauterine pregnancy]. / Diagnostichni problemi pri izvunmatochnata bremennost.

The aim of the authors was to investigate reliability of method, used by them, for diagnosis of extrauterine pregnancy EP (EP). 123 women with admission diagnosis: obs. graviditas extrauterine were studied retrospectively. It was established that the abdominal pain together with the triad of symptoms from the vaginal-abdominal examination: congested adnexae, enlarged uterus and painful cavum Douglasi were of great diagnostic significance. The highly predicting value and sensitivity of ultrasound examination women with EP emphasized the substantial contribution of echography for early and exact diagnosis, which together with timely operative intervention could contribute to preserve the reproductive capability of women.

[Immunogenic activity of synthetic brucellosis antigens]. / Izuchenie immunogennoi aktivnosti iskusstvennykh brutselleznykh antigenov.

Experimental data obtained in this investigation indicate that the conjugation of Brucella protective antigen with a polymer carrier essentially increase the immunogenic properties of the antigen. Synthesized vaccinal preparations can be of interest for practical use, as these preparations, while inducing the development of intense immunity, do not impede the diagnosis of brucellosis by serological reactions. The comparative study of the conjugates of Brucella antigen with different carriers shows that the conjugated preparation obtained on the basis of modified dextran possesses high protective potency, which makes it possible to regard this carrier as very promising for further use.