Reverse case in child sexual abuse.

Child sexual abuse is a public health and medico-legal problem in developed and developing countries. Prompted by rare presentations of cases from this issue that change the course and outcome of events, we present the completed criminal-medico-legislative procedure as a contribution to the dynamics of the investigative process from my own many years of forensic practice. Two preschool teachers of late reproductive age from a home for neglected children reported to the State Attorney's Office a former ward of the home, now an older minor, and an auxiliary employee of the same home, for having sexual relations with a two-year-old girl. But the state attorney also ordered an examination of the reported young man, so the reported case that the teachers "saw" penetrative intercourse was rejected by the expert and the state attorney as an action impossible without injuring the girl at that age. Further investigation proved the continuous sexual abuse by two teachers of the young man since he was 13 years old, i.e. for three years, which he did not report for fear that he would be kicked out of the home. He had sexual relations with each of them several times during those incriminated years. After his statement, other employees of the home were questioned as witnesses who confirmed the suspect boy's claims. He was then released from custody, and the teachers were dismissed from their jobs and accused of years of sexual abuse of minors and abuse of their position and authority as competent persons.

Capabilities of perinatal healthcare institutions in primary and tertiary care of low birth weight infants in the Federation of Bosnia and Herzegovina: a cross-sectional multicentric study.

Introduction: Providing adequate healthcare for premature infants is an important issue in perinatal medicine. The aim of this study is to assess the level of the perinatal healthcare institution (PHI) where the newborns were delivered and the possibilities of transporting them to the cantons of the Federation of Bosnia and Herzegovina. The authors also aimed to examine the overall survival of low birth-weight infants (LBWI) in the Federation of Bosnia and Herzegovina and to compare the survival of newborns according to the PHI where they were born and the PHI where they were treated. Materials and methods: This cross-sectional study included newborns of both sexes that were born in the maternity wards in 10 cantons of the Federation of Bosnia and Herzegovina with a gestational age between 22 and 42 weeks, and a birth weight less than 2500 g. Result: From the PHI of the first and second level, 159 newborns were referred to the third level. A total of 159/669 (23.7%) were referred from a second level PHI to a third level PHI, and 127/669 (l8.9%) LBWI were definitely taken care of. A total of 513/669 (76.8%) LBWI were definitely taken care of in the third level PHI. Out of a total of 159 LBWI referred from other PHI, only 31 (19.5%) LBWI were transported in less than 4 h, and 128 (80.5%) newborns were admitted to the third level PHI within 4 h of birth (P<0.0001). In second level PHI, most LBWI died in the first 12 h after birth, while in third level PHI, 69.2% of LBWI died after 1 week of life. Conclusion: Based on world experience and assessment of the situation in Federation of Bosnia and Herzegovina, it is necessary to take measures to improve perinatal care and its regional organization.

Full trisomy 14 in one of bichorionic biamniotic twins.

We describe the case of the lethal full trisomy (T) 14 in a fetus from bichorionic biamniotic (BCBA) twin pregnancy. This is a case of a 28-year-old primigravida, with an unremarkable personal and family history, who just like her 30-year-old husband, was without consanguinity between spouses. She conceived spontaneously, without a burdened gynecological-obstetric history. By the 12th week of pregnancy, she had hyperemesis gravidarum and one episode of bleeding due to which progesterone supplementation was prescribed. Due to asymptomatic bacteriuria, she took cefuroxime axetil in the 13th week of pregnancy and azithromycin in the 15th week due to cervicitis with ureaplasma urealyticum.

Severe Early-Onset Intrahepatic Cholestasis of Pregnancy Following Ovarian Hyperstimulation Syndrome with Pulmonary Presentation after In Vitro Fertilization: Case Report and Systematic Review of Case Reports.

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disease, usually presented in the third trimester with pruritus, elevated transaminase, and serum total bile acids. Evidence shows that it can be developed in the first trimester, more commonly after in vitro fertilization (IVF) procedures, with the presence of ovarian hyperstimulation syndrome (OHSS). METHODS: A literature search was conducted in the PubMed/MEDLINE database of case reports/studies reporting early-onset ICP in spontaneous and IVF pregnancies published until July 2023. RESULTS: Thirty articles on early-onset ICP were included in the review analysis, with 19 patients who developed ICP in spontaneous pregnancy and 15 patients who developed ICP in IVF pregnancies with or without OHSS. Cases of 1st and 2nd trimester ICP in terms of "early-onset" ICP were pooled to gather additional findings. CONCLUSIONS: Proper monitoring should be applied even before expected pregnancy and during IVF procedures in patients with known risk factors for OHSS and ICP development (patient and family history), with proper progesterone supplementation dosage and genetic testing in case of ICP recurrence.

Internal manual rotation in intrapartal arrest of fetal head engagement.

OBJECTIVE: The success of internal manual or digital rotation of the head in mechanical dystocia due to malpresentation, malposition or malrotation is presented in this paper on our own clinical material with reference of today's research and clinical recommendations. STUDY DESIGN: Through a retrospective bicentric clinical study, we investigated the success of internal head rotation in two University Clinics for gynecology and obstetrics from year 2017 to 2023. In 152 singleton term (37-42 weeks) in cases of persistens intrapartum arrest of the fetal head. After palpatory and ultrasonographically verified arrest of fetal head engagement, a therapeutic manual (Liepmann) or digital rotation was performed. RESULTS: In 152 cases, manual rotation was performed in 108 (71.05 %) and digital rotation in 44 (28.94 %) cases in 73 (48.02 %) primiparous and 79 (51.97 %) multiparous. Intrapartum identification by digital palpation was done in all cases, and the following are: persistent occipital posterior position in 68 (44.73%), persistent deep transverse head presentation in 12 (7.89%), persistent high (longitudinal) occipital presentation in 64 (42.10 %) and persistent anterior asynclitism in 8 (5.26 %) cases. Episiotomy was used in 36 (23.68%) cases. Vacuum extraction was completed in 14 (9.21 %) deliveries, and cesarean section due to unsuccessful internal rotation in 15 (9.8 %) cases (%) without other indication. We did not record any intrapartum complications or cardiotocographic abnormalities. Cervical lacerations were treated with sutures in 4 cases (2.63 %). Successful correction of internal rotation procedure with spontaneous vaginal delivery was found in 80.92 % of cases. If we exclude delivery assisted by vacuum extraction whose indications were fetal hypoxia or dystocia after successful internal head rotation procedure, then the success rate of this method was 90.13 %. CONCLUSION: Internal head rotation is a simple, safe and successful obstetric manual intervention that directly increases the rate of vaginal deliveries after correction of the birth mechanism anomaly and directly reduces the percentage of cesarean section. Manual or digital head rotation is an established midwifery/obstetric skill in several centers which, based on numerous clinical researches and experience, should become protocolized and included in the guidelines of professional associations.

Viable invasive cervical pregnancy treated with minimally invasive procedures.

With an incidence of 1% of all ectopic pregnancies, cervical ectopic pregnancy (CEP) is due to possible early misdiagnosis or bleeding and rupture can become a life-threatening condition with the need for urgent hysterectomy, which has been seen in clinical practice recently. We present a case of early diagnosed invasive CEP treated with combined minimally invasive procedure (MIP) due to acute pelvic pain and bleeding. In our case, we applied several of these methods to a primigravida with early invasive CEP with fertility preservation. By combining the self-described local medications with uterotonics and cervical anaemia treatment, intravenous tranexamic acid and MIP, we were able to preserve the uterus with minimal blood loss and the possibility of future conception.

Fatal iatrogenous neonatal massive air embolism with diffuse emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum.

PURPOSE: Fatal neonatal pneumothorax is often described in the literature as a consequence of prematurity and respiratory distress syndrome, pulmonary congenital anomalies, artificial ventilation and cardiopulmonary resuscitation. METHODS: Forensically clinical commentaries of the letal complications in perinatal malpractices. RESULTS: After an orderly term delivery in a 31.- year old tercipara, the newborn developed a clinical sign of meconium aspiration syndrome, for which he was primarily resuscitated with an APGAR score of 3,5,6. In the neonatology department, one hour after delivery, severe generalized emphysema and massive air embolism developed with bilateral pneumothorax, pneumomediastinum, pneumopericardium and pneumoperitoneum, as well as cardiac arrest and death. A direct connection between the oxygen supply pipe and the endotracheal tube was found with the consequent continuous overpressure and hyperoxygenation as the cause of the above pathological conditions, which were confirmed by autopsy with a massive air embolism. CONCLUSION: For a forensic-clinical discussion, I consider this rare presentation of a massive lethal air plurifocal embolism to be a necessary contribution to the understanding of professional, educational and organizational communication failure. Alveolar overdistension with hyperinflation of oxygen led to imposibility of spontaneous and assisted ventilation, massive air embolism and consequent complications that led to death without response to resuscitation measures.

Pure uterine lipoma - a paradoxical rarity.

Pure uterine lipomas are extremely rare benign uterine tumors. This paper presents the case of a 68-year-old patient with symptomatic leiomyoma-like fundus formation on ultrasound. A hysterectomy was performed with anterior vaginal plastic surgery as a treatment option for concomitant cystocele grade II. Histological diagnosis of pure uterine lipoma with S-100 positive immunohistochemical staining was confirmed. This case shows us that uterine lipoma clinically and diagnostically mimics myoma very well. We believe that surgery as a therapeutical approach is justified in symptomatic patients.

The proposal of the novel fetal shoulder dystocia graduation: a clinical-based opinion.

BACKGROUND: Shoulder dystocia is a peracute mechanical dystocia and a prepartum, usually unpredictable, life-threatening entity with significant forensic implications due to significantly poor perinatal outcome, especially permanent disability or perinatal death. CONTENT: To better objectify the graduation and to include other important clinical parameters, we believe it is appropriate to present a proposal for a complete perinatal weighted graduation of shoulder dystocia, based on several years of numerous other and our own clinical and forensic studies and thematic biobibliography. Obstetric maneuvers, neonatal outcome, and maternal outcome are three components, which are evaluated according to the severity of 0-4 proposed components. Thus, the gradation is ultimately in four degrees according to the total score: I. degreee, score 0-3: slightly shoulder dystocia with simple obstetric interventions, but without birth injuries; II. degree, score 4-7: mild shoulder dystocia resolved by external, secondary interventions and minor injuries; III. degree, score 8-10: severe shoulder dystocia with severe peripartum injuries; IV. degree, score 11-12: extremely difficult, severe shoulder dystocia with ultima ratio interventions applied and resulting extremely severe injuries with chronic disability, including perinatal death. SUMMARY: As a clinically evaluated graduation, it certainly has an applicable long-term anamnestic and prognostic component for subsequent pregnancies and access to subsequent births, as it includes all relevant components of clinical forensic objectification.

Women's sexual abuse: forensic-gynecologic expertise experiences.

PURPOSE: Women sexual violence as a gynecological, social-criminological and gynecological problem has no declining trend in developing and developed countries, including in Croatia. METHODS: From my own 23-year forensic-gynecological expertises practice, along with the results of legally completed examples of sexual abuses, as a contribution to this problem, which is also read from other works. RESULTS: Of the cases of sexual abuses (n = 31) with a median age of 37 years, gynecological-forensic expertise proved and confirmed 67.7% of sexual abuses criminal cases with a significant problem of inadequate primary gynecological procedure, most often due to insufficient gynecological examination and medical documentation in high 64.5%, as well as late sexual abuses report in 51.6%. Of all cases of sexual abuses, 6 (19.4%) required primary surgical care due to bleeding and lacerations of the genitals, there were no reported cases of sexual abuses in pregnancy, and no deaths related to sexual abuses. The problems that can affect the forensic-gynecological evaluation of sexual abuses victims are: inadequate and insufficient primary medical documentation immediately after sexual abuses, late reports of sexual abuses, after several days, months and years in the reproductive age of women, with a late primary examination and an almost difficult to prove objective gynecological examination and inadequate education of gynecologists in primary examination. CONCLUSION: In conclusion, it should be mentioned that the mentioned medical problems can be solved by constant education of all professional medical participants, permanent court experts with experience, coordination and subordination of expert gynecological and forensic societies in cooperation with the state attorney's office, courts and police, and social service.

Papillary thyroid carcinoma within a mature cystic ovarian teratoma.

Mature cystic ovarian teratoma (dermoid cyst) is the most common germ cell tumor. Malignant tissue alteration in mature cystic teratoma is extremely rare, and malignant proliferation of thyroid tissue has been documented in only a few cases. This article presents a case of incidentally detected papillary microcarcinoma (PTMC) within a mature cystic ovarian teratoma. A 42-year-old patient with an ultrasound-suspected dermoid cyst was indicated for surgical treatment. Laparoscopic adnexectomy was performed, and a cystic-solid tumor 3.5 cm in diameter was removed entirely. Pathohistological analysis confirmed the diagnosis of a mature cystic teratoma with a PTMC 0.3 cm in diameter. Afterward, the patient underwent additional investigations with an oncologic radiotherapist and endocrinologist. Thyroid ultrasound, thyroglobulin serum levels, anti-thyroglobulin antibodies, thyroid scintigraphy, and abdominal positron emission tomography (PET) scan were performed to exclude disease dissemination. All results were with no findings of other disease seed/metastasis, and the patient will be followed up regularly by a gynecologist and endocrinologist.

Sexual abuse of children - some recommendations from a forensic gynaecologist's expert experience.

Prompt and better primary examination of victims accompanied by meticulous note-taking in cases of suspected child sexual abuse are needed to improve both conviction rates and to avoid inappropriate criminal investigations and proceedings. The majority of child sexual abuse victims are female. More training is needed for gyaecologists in this field.

Hemispherotomy in an infant with hemimegalencephaly and Ohtahara syndrome.

We represent the case of a premature twin neonate born from uncomplicated pregnancy who developed seizures at the age of 24 h. Two-dimensional ultrasound and magnetic resonance imaging revealed left-sided hemimegalencephaly. Further extensive diagnostic evaluation revealed a diagnosis of Ohtahara syndrome. Resistance of the seizures to antiepileptic therapy led to hemispherotomy that was performed at the age of 10 months. Our patient is now a 4-year-old child, walking, eating without a nasogastric tube, still with right hemiparesis and lateral strabismus but without seizures.