[ASPHYXIA IN INTRAUTERINE GROWTH RESTRICTION OF THE FETUS- CARDIOTOCOGRAPHY AND ULTRASOUND METHODS OF DIAGNOSIS.]

Fetal asphyxia remains an important cause of neonatal morbidity and mortality. The tests in themselves (cardiotocography (NST), sonography, Doppler studies) which are used for antenatal fetus surveillance are aimed at timely diagnosing the signs of the fetus asphyxia. The objective of the current research is to study which modifications in the cardiotocography (NST), arterial and venosus Doppler correlate most strongly with severe asphyxia pH< 7.10 and BE≥12 mmol/l regarding pregnancies which are complicated with intrauterine growth restriction of the fetus. The presence of spontaneous decelerations in the cardiotocography shows sensitivity 81.3%, specificity 97.1%, positive predictive value (PPV) 83.2, negative predictive value (NPV) 98.2%, odds ratio (OR) 260, p< 0.0001, the reversed blood velocity of artery umbilicalis shows sensitivity 58.3%, specificity 96.2%, PPV 63.6%, NPV 95. 3% OR 35.7 p< 0.001, reversed a-wave ductus venosus shows sensitivity 51%, specificity 94.3%, PPV 48% NPV 93.2% OR 16.7, p< 0.001. Concerning pregnant women with intrauterine growth restriction of the fetus the prognostication of severe fetus asphyxia at delivery - pH<7. 10 and BE -12 mmol/I with the highest specificity of antenatal testing is the occurrence of spontaneous decelerations in NST, the reversed blood velocity of umbilical artery and the reversed a-wave ductus venosus in Doppler studies.

[Anormalies of the fetal posterior fossa during second trimester--diagnosis and management].

Six cases of Dandy-Walker malformation are presented. Five of them, diagnosed in 18-20 gestation weeks, respectively ended up in intermission of the pregnancy in second trimester and one case, diagnosed in 29-30 gestation weeks ended up in giving birth to a hypotrophical foetus in a good general state. The opportunities for diagnosis by 2D/3D echography have been considered in accordance with the new classification of abnormality of the fetal posterior fossa fluid collections. This is a clinical approach and a possible way out for the pregnancy and the new-born baby.

[Placenta accreta--prenatal diagnosis, treatment].

Placenta accreta is a potentially life threatening obstetric condition that requires a multidisciplinary management. Placenta praevia and previous Cesarean section are the two most important known risk factors for placenta accreta. This study presents two patients having both of the foremention risk factors diagnosed ultrasonographically with placenta accreta in the second trimester. Ultrasound findings considered suggestive of placenta accreta are: presence of placental lacunae (vascular spaces), loss of the hyperehoic uterine serosa-bladder wall interface, loss of the retroplacental hypoechoic clear space, hypervascularity of the interface between the uterine wall and the bladder wall/isthmico-cervical zone, presence of placenta praevia, either anterior or posterior, overlying the uterine scar. Both of the cases with suspected placenta accreta ended successfully by planned preterm Cesarean hysterectomy with the placenta left in situ. Placenta accreta is a significant cause of maternal morbidity and mortality and the most common reason for urgent postpartum hysterectomy.

[Giant orofacial teratoma of the fetus (epignathus) - prenatal 2d and three-dimensional 3D ultrasound detection of this rare condition].

An epignathus is an extremely rare form of oropharyngeal teratoma that arises from the oral cavity, most commonly from the palate and is associated with a high mortality secondary to airway obstruction in the neonatal period. We present a case of prenatal diagnosis in 29 w.g. preterm baby with a giant epignathus, preterm birth and fetal death. We discuss the incidence of these tumors, the antenatal diagnosis and the prognosis and management of this condition.

[Spontaneous uterine rupture in third trimester twin ivf pregnancy following myomectomy].

Uterine rupture is one of the most serious complications of pregnancy, causing maternal and perinatal death. An increased risk of uterine rupture is associated with uterine scars caused by previous cesarean section, myomectomy, hysteroscopic procedures and ART treatment. We report a case of 35-year-old nulliparous woman with a twin pregnancy who experienced a spontaneous uterine rupture at 30 weeks' gestation. She had a previous history of one opened myomectomy, two laporoscopic procedures for extrauterine pregnancy and myomectomy in the left uterine corn. Her pregnancy was established with in vitro fertilization 14 months after the laparoscopic myomectomy. The uterine rupture was heralded by a sudden onset of severe abdominal pain while she was having a routine exam. This case reinforces that pregnancy after myomectomy should be closely monitored with respect to uterine rupture.

[Characteristics of the severe fetalanomalies terminated in general obstetrics department for 4,5 years period].

UNLABELLED: The most common reason for interruption in second trimester is: Foetus mortus, malformations, severe intrauterine retardation, oligohydramnios, PPOM, cervical insufficiency, incomplete abortion. The aim of this study was to evaluate and analyze the distribution of incidence and type of severe fetal malformations, terminated at the end of first and second trimester in General obstetrical department in University hospital "Maichin dom"- Sofia for a period of 4 years and 5 months - retrospectively and prospectively. RESULTS AND DISCUSSION: Patients were aged between 16 and 42 years. The termination of pregnancies was in gestational period between 11.5 and 28 weeks. The study period is from the beginning of 2007 until May 2011. In the department have been terminated a total number of 907 pregnancies, 219 cases in second trimester and 61 of them due to fetal malformation, diagnozed between 11.5 to 28 weeks The incidence of fetal abnormalities was 27.8% (61 cases) of all terminated pregnancies in second trimester (219 cases). The results showed the highest rate of malformations in the age group 21-35 years - 62.3%. The highest percentage of malformations are in gestational age: 18-22 weeks - 59%. The highest incidence are as followed: neural tube defects (24.59%) and central nervous system (21.29%), followed by chromosomal defects confirmed by amniocentesis (11.47%), cardiac defects (9.83%), facial clefts (6.54%). The most common gestational age in which the anomalies are diagnosed and terminated is 18-22 weeks. The upper limit for termination of pregnancy on legislation is 22 weeks (globally 22-24 weeks). Ethical and social considerations in all cases of severe abnormalities and possible variations in physical and mental and intellectual development of the infant are discussed, these pregnancies, either diagnosed late and/or after karyotiping require termination of the pregnancy in late pregnancy

[Rupture of splenic artery aneurysm--life-threatening condition for women during pregnancy and after birth (with report of one case)].

Spontaneous rupture of a splenic artery aneurysm is an uncommon and usually catastrophic event during pregnancy and puerperium. The mortality rate among pregnant women is very high at 75% with a fetus mortality rate of 95%. This report describes the clinical course of a 25-year-old woman with hemorrhagic shock four hours after elective Cesarean Section. Symptoms like hypotension, tachycardia, dyspnoe were initially suggestive of pulmonary embolism. Ultrasound demonstrated a nonechogenic mass in the abdomen suggestive of a fluid collection. Ruptured splenic artery aneurysm was recognized during the second emergency laparotomy for hemoperitoneum. Splenectomy was performed. The outcome for the patient was good. We underline that the only way to avoid a fatal event is to know and to think about this rare but very important complication in any woman with unexplained abdominal pain or with clear signs of haemorrhage during pregnancy or shortly after delivery.

[Autoimmune thrombocytopenia during pregnancy (case report and review of literature)].

A case of autoimmune thrombocytopenia [AIT], diagnosed in the first trimester of pregnancy is described. Despite the active treatment with steroids and IVIG the platelet count dropped to extremely low levels in the third trimester--8 x 10(9)/l. Labor was induced in 34 w.g. because of the ineffective treatment of AIT, clinical and sonographic evidence of IUGR and favorable pelvic score. Before and during labor induction platelets were transfused and recombinant factor VIIa (rFVIIa) was applied. After delivery antifibrinolytics as well as low molecular weight heparin [LMWH] were applied also. Laboratory tests demonstrated transient fibrinolysis activation after delivery. Mild transient thrombocytopenia of the newborn was found that was successfully treated with steroids. Review of contemporary literature is made with analysis of the therapeutic approaches in cases of AIT during pregnancy. The impact of thrombocytopenia on pregnancy, labor and delivery, the fetus and the newborn and the route of delivery are discussed. The clinical course and the therapeutic strategies in the particular case are analyzed. A nouvelle approach during labor and after delivery was the application of rFVIIa (because of the tendency for elevation of the titers of allogenic antibodies due to platelet transfusions) and of antifibrinolytics (preserving platelet functions).

[The efficacy of the misoprostol in cases of abnormal and pathologic hypotonic hemorrhage in the early puerperium].

UNLABELLED: The aim of this study is to determine the efficacy of the Misoprostol (Cytotec) in cases of abnormal and pathologic hypotonic hemorrhage in the early puerperium as a result of hypotonia of the uterus. MATERIAL AND METHODS: A group of 50 women with vaginal or abdominal labor developing hypotonic abnormal/pathologic bleeding after the placental delivery were given Misoprostol (Cytotec 200-400 microgr per rectum and/or per oral every 15 min). We compared this group with a control group without having postpartum bleeding. RESULTS: The application of Misoprostol resulted in uterine contraction and discontinuing the abnormal bleedings in both vaginal and Caesarian deliveries. The main blood lost in the next two hours period after vaginal labor didn't differ with the blood lost of the normal labors (66 ml vs. 75 ml). In the Caesarian deliveries the blood lost after application of the Misoprostol also didn't differ with the blood lost after normal caesarian section (78 ml vs. 80 ml). CONCLUSIONS: Misoprostol decreases the hypotonic uterine bleedings in the placental and early puerperal period. The significance of the Misoprostol in the group of therapeutic events is determined by its fast therapeutic effect, its convenient application and its good tolerance.

[Cervical cerclage--when is it effective?].

OBJECTIVE: To compare the effectiveness of the different types of cervical cerclage (primary, secondary and tertiary) for prevention of preterm deliveries and second trimester abortions. MATERIALS AND METHODS: The study is retrospective, including 145 pregnant women with history and/or clinical signs of cervical incompetence. In 86 cases cervical cerclage has been performed while in the remaining 59 cases management has been expectant. Among the patients with cerclage 57 had primary, 25 had secondary and 4--tertiary cervical suture. In 21 cases cervical length was measured by transvaginal ultrasound. In 9 cases cervical length was < 25 mm and in the remaining 12 cases-- > or = 25 mm. RESULTS: Cervical suture placement and expectant management were found to be equally effective in patients with indications for primary cerclage. On the contrary, in patients with indications for secondary cerclage mean gestational age at delivery and the percentage of patients that remained undelivered after 34 w.g. were higher in the subgroup that had cerclage compared to the one that was treated expectantly. In patients with indications for tertiary cerclage pregnancy outcome was similar in the subgroups with and without cerclage and in general was unfavorable. Gestational age at delivery was higher if the cerclage was placed before 18 w.g. and if cervical length was > or = 25 mm.

[Cesarean section for fetal distress--is the decision interval for delivery significant?].

UNLABELLED: The recommended Interval between the decision to perform emergency cesarean section and the delivery itself is 30 minutes. There is not enough clinical evidence in maintenance of this opinion. AIM: to study the interval from the decision of the cesarean section for fetal distress to delivery itself, as well as to analyze fetal and mother's outcome. METHODS: Prospective 13-month-study for the period 2003-2004 in Delivery room "Majchin Dom" included observation of 125 women. Cesarean section is classified in 3 Categories--1st--deemed highly hazardous for mother or/and fetus (crush); 2nd--not directly hazardous for mother or/and fetus (emergency); and 3dt--not direct mother or/and fetal distress, but the delivery is necessary in a short period of time (urgency). The Interval and the Categories are comparable with the presence or absence of fetal distress (Apgar < 7, pH < 7.20). RESULTS AND DISCUSSION: Positive results are found in the 1st category when the C-section is performed in 30 minutes. There are significant differences between the three Categories--the percentage of fetal distress is growing up comparable to prolongation of the time interval. Prolongation of the time interval for more than 60 minutes lead to poor fetal outcome.

[Pulmonary embolism and disseminated coagulopathy syndrome after first trimester termination of pregnancy--a case report].

We present a rare case report of first trimester termination of pregnancy by suction curettage because of missed abortion complicated by pulmonary thrombembolism and disseminated coagulopathy. The diagnosis was confirmed by clinical, sonographical and laboratory means. The relative risk of such complications after first trimester termination of pregnancy is discussed.

[Reference values range of the fetal oxygen saturation and its dispersal during labor without cardiotocographic evidence for fetal distress].

UNLABELLED: The objective of this study is to establish the reference values range of the fetal oxygen saturation during the first and the second period of labor and their dispersal according to the extent of cervical dillatation in cases with normal FHR--absence of fetal hypoxia and asphyxia of the newborn. MATERIAL AND METHODS: This is a prospective study which involves 94 women with normal FHR. All of the newborns are with umbilical artery pH values greater than 7.15 and 5 min Apgar score greater than 7; there was no necessity for any reanimation procedures, assisted ventilation or intensive care treatment. The fetal oxygen saturation (SpO2) is monitored by fetal pulseoxymeter Nellcor N 400, fetal sensors FS - 14. Cardiotocographic monitoring is carried out simultaneously. Blood is obtained from the fetal scalp during labor for blood gas and pH analysis, and umbilical artery pH as well as the Apgar score of the newborn are determined. RESULTS: The average monitoring time during the first period of labor is 107.19+/-29.49 min. with reliability of the recordings 86.54+/-6.10%. The average monitoring time for the second period of labor is 36.72+/-8.31 min. with reliability of the recordings 75.42 +/-9.61%. The mean SpO2 values are 48.71+/-5.52% during the first period and 47.30+/-4.62% during the second period of labor. The reference SpO2 values ranging between the 25-th and 75-th percentile in fetuses with normal FHR are 46-52 % for the first and 44-50 % for the second period. The results for fetal SpO2 during the different stages of cervical dillatation are as follows: for 4-5 cm - 49.49+/-5.12%, for 6-7 cm - 48.76+/-5.42%, for 8-9 cm - 48.39+/-5.49%. CONCLUSIONS: The fetal SpO2 dispersal during cervical dillatation of 4-5, 6-7 and 8-9cm accordingly demonstrates a nonsignificant decrease of SpO2 for the different groups (p>0.05). The fetal SpO2 dispersal between the first and the second period of labor also demonstrates decrease of SpO2 values and shows a minor statistically significant difference (p < 0.05 - Repeated measures ANOVA), which is considered to be within the normal range and does not reflect on the newborn's well-being.

[Localization of leiomyoma with respect to the placenta--factor for complications during pregnancy?].

We are presenting two cases of pregnant women with leiomyoma of the uterus, diagnosed antepartum. In both cases the patients were admitted on an emergency basis due to premature uterine contractions. In both cases preterm hemorrhage and fetal malpresentations were observed. The complications of pregnancy in both of the cases were primarily based on the location of the leiomyoma with respect to the placenta--intramural or submucosal disposition of the leiomyoma, retroplacentarily situated.

[Post-operative complications following elective and emergency caesarean delivery].

AIM OF THE STUDY: 1) To analyze the frequency of complications after elective/planned [PCS] and emergency Cesarean section [ECS]; 2) To compare the types of complications in the two evaluated groups; 3) To analyze the possible risk factors for complications after elective and emergency procedures. METHODS: The study was retrospective, hospital-based one. Data regarding complications following Cesarean section [CS] that demanded transfer of the patients to The Clinic of High Infectious Risk, State University Hospital "Maichin Dom", Sofia and prolonged hospital stay (more than 7 days after the operation) were analyzed. The incidence of complications in 574 consecutive PCS and in 292 ECS was calculated. The type of the following complications was compared in the two groups: uterine infections (endo/mio/ metrophlebitis), wound infection, subfascial hematoma, residua, sepsis, pelvic thrombophlebitis. Statistical evaluation of the results was performed by Student's t-test with p<0.05 considered statistically significant. RESULTS: In 574 PCS the frequency of postoperative complications was 1,4% while in 292 ECS it was 2,05% (p>0.05). There was not significant difference in the distribution of the different types of postoperative complications in 34 cases with PCS and 33 cases with ECS. The percentage of patients with previous CS was significantly higher in the complicated cases with PCS compared to that with ECS. The two studied groups do not differ significantly regarding the type of skin incision, operator's qualification, blood loss, drainage of the subfascial space, accompanying diseases. CONCLUSIONS: Cesarean section constitutes a major surgical procedure characterised with morbidity even if performed as a planned procedure. The risk of complications seems to be higher in cases of repeated CS. Patients that demand CS without medical indications have to be informed and be aware of these facts.

[Shoulder dystocia--risk factors and fetal outcome]. / Ramenna distokiia--riskovi faktori i izkhod za ploda.

The purpose of this retrospective study is to evaluate the perinatal outcome in cases with birth injuries, suggesting shoulder dystocia. This survey involves 92 cases of live newborns (gestational age between 37 and 42 weeks) with shoulder injuries. Another control group of 120 cases of live mature newborns without any shoulder injuries is studied for comparison. There are no significant differentialities between those two groups, regarding age, parity, weight and height of the parturients. Shoulder dystocia is most frequently found in newborns of 3500-4000 g birthweight. Antepartum, risk factors for shoulder dystocia are: diabetes, obesity of the mother and chronological postterm pregnancy. Intrapartum, the evaluated risk factors prove to be unreliable because the same were found in as many as one half of the non-traumatic vaginal deliveries. In 27% of the cases, shoulder dystocia occurs most probably after the passage of the shoulder through the pelvic inlet. The most frequent type of shoulder injury is fracture of the clavicle (90.2%), followed by paresis of the brachial plexus (7.6%). Severe shoulder dystocia both from obstetrical and neonatological point of view is found in 2-3% of the cases.

[Study of women preference regarding mode of delivery]. / Prouchvane naglasata na zhenite za nachin na rodorazreshenie.

The aim of this inquiry study is to assess the women's preference for abdominal or vaginal delivery in 113 women, divided in tree subgroups: 38 nonpregnant, 38 pregnant with one more births and 37 puerperas. All women are with high education and 49.6% of them had past at least one university exam of obstetrics and gynecology. 42.1% of nonporous women and 40.9% from parous would like to deliver CS. With the time from vaginal delivery the preference for vaginal deliver again decreases from 84.2% to 60.9% of cases. All women delivered by CS prefer CS again. Complications of vaginal delivery are factor for increasing CS rate. The pain relief of vaginal delivery does not increase the preference for vaginal deliver again. In 40% of women there is steady desire for vaginal delivery despite previous complications or full medical information for the concrete conditions. 88.5% of inquired women agree with "CS on request".

[Supplemental multivitamin and multimineral preparations during normal pregnancy--effect on a fetus and delivery]. / Multivitamini i multimineralni preparati pri normalno protichashta bremennost--efekt vurkhu ploda i razhdaneto.

UNLABELLED: The aim of this prospective study is to assess the effect of non indicated supplementation with Materna during normal pregnancy on some parameters of the neonate and the process of delivery. The material includes 98 women who had been taking Materna during the pregnancy and 27 cases without any medications. The criteria for inclusion are: normally progressing clinically and paraclinically pregnancy and delivery after completing 37th w.g. (95% confident interval 39.0-40.5). RESULT: Most of the pregnant women take Materna for 3 to 5 months (95% CI) during pregnancy. The supplementation with Materna lead to increase of the BIP from the control group of 94.4 mm to 96.5; the occipitofrontal circumference from 33.9 to 35.1 and the high of the neonate from 50.2 to 51.1 respectively. The impression of the obstetricians engage in the study is that the scull bones are more solid and the molding of the head after the delivery is very small or even missing. CONCLUSION: Unjustified supplementation of normal pregnancy with multivitamins and multiminerals lead to increase in the occipitofrontal circumference and to the decrease of the molding capacity of the fetal head wherefore the labor prolongs and the rate of CS and the operative vaginal deliveries increase.