[CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETE DURING VAGINAL DELIVERY].

Conservative management of placenta accrete consists in leaving the entire placenta accreta in situ after vaginal delivery of the fetus. This behavior requires active monitoring the vital signs of mother, genital status and paraclinical indicators for an extended period after birth. Monitoring is suspended after full absorption of the placenta. The success of the conservative approach depends on: the adopted protocol formanagement of placenta accreta, whether the diagnosis is known before birth, the possible of application techniques, reducing blood flow to the uterus, keeping the placental period and others. The smallest success with vaginal birth, is when the diagnosis of placenta accreta is not know in advance and proceed with aggressive attempts to extract the placenta, followed by profuse bleeding from the uterus. As additional methods of securing conservative management is reported use of Methotrexate, with unproven effectiveness and embolization of a. Iliaca interna and a. uterine, which require a qualified team and have a lot of complications. Complications of conservative management of placenta accreta are: febrility and genital bleeding, which are the cause of late hysterectomy in about 35% of cases. lnfestion may be not always prevent by application of broad spectrum antibiotics. Late bleeding is usually associated with an active inflammatory process. Low-grade and low grade temperature increase of leukocytes and CRP may be due to necrotic changes in the placenta without the infection process. Tracking involution of the placenta is through abdominal and transvaginal ultrasound, magnetic resonance, using hysteroscopy through serial monitoring the level of hCG. From literature data the time for resorption of the placenta varies from 4 months to 1 year. It is essential to determine the time when it is safely to extract the placenta move in order to prevent late complications of conservative management. Our experience and some authors suggest that there may be instrumental extraction under ultrasound control at 8-10 days after birth.

[MANAGEMENT OF PLACENTA ACCRETA, DIAGNOSED BEFORE BIRTH].

The optimal management of placenta accreta and until now remains unclear. The reasons for this are a rarity of this condition and the considerable heterogeneity of the group under the term "placenta accreta." Total hysterectomy during caesarean section is the most common approach to a known placenta accreta. Planned or emergency perinatal hysterectomy is associated with several complications--damage to the urinary tract, relaparotomiya, massive blood transfusions and stay in ICU. The average blood loss is about 3000 ml. To reduce blood loss in perinatal hysterectomy contribute: preliminary uterine artery occlusion, istmus-coporal longitudinal hysterectomy for extraction of the fetus, placental extraction along with the uterus. To save the woman's uterus at placenta accreta are using the following methods: cutting the uterine wall on which is located the placenta, imposing single stitches covering 2-3 cm in 1 cm, around the placental area; removal of the maximum possible part of the placenta; using longitudinal hysterectomy. So far, there are no comparative studies of the efficacy of different surgical techniques to preserve the uterus cases of placenta accreta. Extraction of the placenta to be done after the administration of uterotonics and devascularization the uterus. To reduce bleeding from the uterus after removal of parts of the placenta and according to the situation can be used: x-back hemostatic sutures from internal side of the uterus, tamponade with gauze roll, balloon catheters or haemostatic mushrooms. Conservative surgical treatment of placenta accreta is not always possible. In hospital Maternity Hospital-Sofia for the period 1986-2000 there were 17 cases of placenta accreta diagnosed only at birth. Maintaining the uterus was successful in 35% of these cases.

[Plasma D-dimer levels in preeclampsia].

Preeclampsia is a multifactorial disease characterized by hypertension and proteinuria after 20 weeks of gestation of the pregnancy. Preeclampsia is characterized by the deposition of fibrin in the walls of small blood vessels. D-dimer was used as a marker for degradation/synthesis of fibrin in vivo. D-dimer has emerged as a useful indicator in the diagnosis of thrombotic conditions because its plasma concentration has a high predictive value for the assessment of venous thromboembolism. The purpose of this study was to evaluate plasma levels of D-dimer and preeclampsia compared to normal pregnancy occurs. We found that elevated levels of D-dimer is associated with the development of preeclampsia in the third trimester of pregnancy compared with normal pregnancy occurs. Preliminary findings highlight the need for further in-depth studies during pregnancy in order to fully clarify the diagnostic/prognostic role of D-dimer preeclampsia.

[Location of the placenta in pregnancy with previous caesarean section].

Previous Caesarean section (SC) is considered to be established predisposing factor for abnormal placentation. In this study we examined whether prior SC is a risk factor for low laying placenta. Retrospective documentation was studied of 171 pregnant women after a SC (test group) and of 150 pregnant women after a normal birth (control), and cases of hysterectomy after giving birth to five years. Pathological lying placenta have established at 1.34% in the test group versus 0.67% in controls (p - 0.058), i.e. no proven link between prior Cesarean section and location of the placenta in the lower uterine segment during the next pregnancy. The analysis of cases of postpartum hysterectomy is found that the combination of condition after Cesarean section, placenta praevia and placenta accreta is a risk factor for hysterectomy after childbirth.

[Neonatal bacteremia--frequency, spectrum of organisms and correlation between clinical symptoms and laboratory data for early onset sepsis].

UNLABELLED: Improved obstetrical management and evidence-based peripartum antimicrobial therapy in the last decades reduce the frequency of early-onset neonatal sepsis (EONS) and improve the outcome. The spectrum of the microrganisms is different according to regions, countries and periods of time. Appropriate diagnosis and treatment improve the outcome. However dissociation often occurs between clinical manifestation, laboratory and microbiological findings. AIMS: To determine the incidence of neonatal bacteremia in our hospital, to identify the spectrum of organisms from positive blood cultures (BC), to analyze the correlation between clinical manifestation of EOS and/or laboratory abnormalities. PATIENTS AND METHODS: This study was carried out at the University Hospital of Obstetrics and Gynecology "Maichin dom"- Sofia for 2012. From all 4081 inborn babies 848 were at risk for maternal-fetal infection. In the first two hours after birth they were screened for EONS using a panel of microbiological probes and laboratory blood tests, followed up the next days. According the guidelines of the Neonatology clinic a standard antibiotic therapy was started. 43 of the screened infants (1.05% of all inborn babies) had positive BC and were enrolled in this study. RESULTS: Sixteen from the 43 babies with positive BC were with birthweight > 2500g (0.48% from all 3316 life born term infants), 27--with birthweight < 2500g (3.5% from all 765 low birthweight babies), 24 were patients of the NICU (3.8% of all 635 babies admitted at the NICU for 2012). No one died. The following groups of organisms in BC were isolated: 24 BC with coagulase-negative Staphylococci, Methicilline sensitive (MSCoNS)--11 of them without any clinical symptoms and laboratory abnormalities were interpreted as result of contamination, 1 BC with Staphylococcus aureus MS (MSSA), 8 with alpha-Streptococci, 5 with Enterococcus faecalis (1 in combination with MSCoNS), 2 with GBS, 2 with Aerococcus urinae and 2 BC with Listeria monocytogenes. Gram-negative organisms were not found in BC after birth. 30 from the infants with positive BC didn't show any clinical symptom of EONS. 20 of them were without laboratory criteria for infection and were discharged after negative BC control. 10 newborns were with transient elevation of CRP but without clinical symptoms. 13 babies showed clinical symptoms of EOS, 3 of them had transient respiratory failure, but negative laboratory criteria. 10 babies met the clinical and laboratory criteria for EONS; in 8 of them the CRP was significantly elevated. Most critically ill were 3 ELBW and ELGA babies: 2 twins with Listeria and 1 baby with MSSA-EONS. CONCLUSIONS: In our study, CoNS were found to be the most common cause of EONS or bacteremia, low incidence of GBS sepsis was established. Almost the half of the babies with positive BC were asymptomatic and without laboratory data for infection. Elevation of the CRP-value was the most frequent laboratory abnormality in symptomatic infants.

A study on early-onset neonatal group B streptococcal infection, Bulgaria, 2007-2011.

This study examines neonatal group B streptococcal (GBS) colonization and its relation to early-onset GBS disease (EOGBSD), based upon the experience of leading obstetrics and gynecology centers in Bulgaria. The objectives of the study were to update neonatal colonization rates and to assess relationships between clinically differentiated cases (culture-proven GBS newborns) and risk factors inherent to the infant and mother, using a computerized file. The neonatal GBS colonization rate ranged from 5.48 to 12.19 per 1000 live births. Maternal-fetal infection (MFI, a provisional clinical diagnosis in culture-proven colonized infants with initial signs of infection that is usually overcome with antibiotic treatment) and/or intrapartum asphyxia (IA) have been demonstrated as the most frequent clinical manifestations, with significant correlations for the primary diagnosis, but not affirmative for the final diagnosis at discharge, resulting from adequate treatment of neonates. MFI and IA were significantly related to prematurity, and reciprocally, prematurity was associated with the risk of MFI, indirectly suggesting that preterm birth or PPROM (preterm premature rupture of membranes, an obstetric indication associated with early labor and delivery, one of the major causes of preterm birth) is a substantial risk factor for EOGBSD. The regression analysis indicated that in the case of a newborn with MFI, a birth weight 593.58 g lower than the birth weight of an infant without this diagnosis might be expected. Testing the inverse relationship, i.e., the way birth weight influences a certain diagnosis (logistic regression) established the presence of a relationship between birth weight categories (degree of prematurity) and the diagnosis of MFI. The proportions and odds ratios, converted into probabilities that a baby would develop MFI, indicate the particularly high risk for newborns with extremely low and very low birth weight: extremely low birth weight (≤1000 g), the probability of developing a MFI is 66%; very low birth weight (1001-1500 g), 81%; low birth weight (the birth weight category including premature and small for gestational age term infants: 1501-2500 g), 40%; normal birth weight (term infants) (>2500 g), 32%. In conclusion, the need to introduce separate categories for early- and late-onset GBS disease in the registration nomenclature of neonatal infectious diseases is highlighted by these results. Drawing up intrapartum antibiotic prophylaxis (IAP) guidelines is also strongly recommended.

[Pregnancy-induced haemolytic anaemia].

This is the clinical case of a primiparous eight month pregnant female, presenting with symptoms of pregnancy-induced acute haemolytic anaemia (haemolytic aneamia provoked by an immune mechanism, intra- and extra-erythrocyte defects, and HELLP syndrome were excluded). The anaemia progressed to become life-threatening for both the pregnant women and the foetus, which brought the following questions into consideration: diagnosis of anaemia during pregnancy; dosing of corticosteroid therapy; possibility of giving birth to a viable foetus and prognosis for next pregnancies. Owing to the inter-disciplinary efforts, the life and health of this pregnant woman were preserved, but the foetus was lost.

[Intraamniotic infection--cause and satellite of preterm birth].

Intraamniotic infection (IAI), most commonly presented as chorioamniotitis, plays a major role in the pathogenesis of preterm birth (PTB). In this study, we sought for signs of IAI through clinical and laboratory parameters (leukocyte count, CRP concentration and IL-6 in maternal blood), and compared those to the newborns' infectious condition. Using cervical and vaginal secretion cultures, we determined the probable causing agents of IAI. We also followed up the therapeutic effect from the use of corticosteroids, tocolitics and antibiotics for the treatment of PTB. The results demonstrated that over 46% of the pregnant women with PTB presented with evidence of IAI. The best diagnostic option to detect an IAI provides maternal blood IL-6, and the combination between leukocyte count and CRP is a must for routine examinations. We did not isolate a single vaginal pathogen but a combination of harmful microbes which provided evidence of a vaginal ecosystem disorder. The combination therapy in over 50% of women had a positive effect on PTB for the period of corticosteroid prophylaxis (72 hrs). From hour 84, antibiotic therapy can no longer control IAI development.

[Multipurpose treatment of vaginal infections].

Untreated bacterial vaginosis is related with many complications for non-pregnant women in reproductive age, most common from them are vaginal discharge and postoperative infections. The aim of our investigation was to compare the effectiveness of two therapeutic regimes which consist in Macmiror/Macmiror Complex alone and in combination with Feminella Vagi C for treatment of bacterial vaginosis (BV) and/or mycotic infection. 117 non-pregnant women with symptoms of vaginal infection were prospectively enrolled into two groups according their treatment. First group consist 66 women treated with Macmiror tablets and vaginal capsules followed with local application of Feminella Vagi C, the second group consist 54 women treated with Macmiror tablets and vaginal capsules only. The impact of treatment on clinical symptoms was observed at the end of medication and 20 days after it. Microbiological testing was repeated 20 days after treatment. Over than 80% (78.6 divided by 86.7%) of the cases with vaginal infection (BV and mycotic one) were successfully treated with Macmiror/Macmiror Complex. Supplement treatment with Feminella Vagi C lead to higher percentage of clinically recovery (86.7% vs 84.6%), better microbiological cleaning (86.7% vs 82.1%) and longer effect of treatment. Used medication showed higher efficacy against BV than to fungal infection. According obtained results we may conclude that bacterial vaginosis was better treated with multipurpose treatment (Nifuratel, Nistatin and vit. C) than with Macmiror alone.

[Role of IL-6 for the diagnosis of preterm birth].

The preterm birth (PTB) is still a problem for the modern obstetrics, with certainly unsolved questions. Mainly this is associated with the lack of chance to decrease its frequency but also due to the tendency of definite change of its structure--high level of extreme premature state. Intra uterus infection (IUI) is one of the major etiologic reasons for PTB. The early detection of IUI and the determination of the level of fetus damage are the leading therapeutic approach to PTB. The present study includes the test reliability of interleukin-6 (IL-6) to diagnose IUI and early neonatal infectivity. The groups of patients are (A) pregnant women with regular term and (B) pregnant women with PTB, both, with ruptured amniotic membrane or with intact ones. The results of their infectious parameters are determined and analyzed: Leu number, CRP and IL-6 in mother's blood and newborn's blood. It is obvious that the highest percent of IUI is detected by using the blood level of IL-6, followed by CRP and Leu number. The most significant correlation is established between PTB and pathologic levels of IL-6 in cord blood (> or = 30 pg/ml, OR-40.09). In conclusion, we could summarize that IL-6 is a reliable parameter and sign for IUI in cases with PTB. It opens the door to a potential application of its laboratory testing, thus allowing a crucial decision with problematic therapeutic cases, when discussing the PTB.

[Finding a developing intrauterine infection in preterm birth by using classic and modern infection indices].

A significant part of preterm births (PTB) are due to a developing intrauterine infection (IUI). This infection is often of subclinical nature, and its diagnosis is mainly based on laboratory measurements. The objective of our study was to compare the diagnostic potential of classic (clinical picture, leukocyte count, CRP) and modern (IL-6) indices of an infectious and inflammatory process. We found the established clinical symptoms of IUI in 4.2% of the women with PTB, and if symptoms such as subfebrile body temperature (37'-37.5 degrees C), and mother's pulse of 90-100 beats/minute are taken into consideration, then with them this infection were diagnosed 23% of the women with PTB. Based on reference values of blood markers, the following incidence rates of infection were established for the studied pregnant women: increased Leu--26.7% for PTB, and 3% for the full-term birth group; based on increased CRP--51.7% for PTB, and no available data on infection for the control group; based on IL-6 over 11 pg/ml--66.7% for the PTB group, and 16.7% for the full-term women. Laboratory markers have the following sensitivity, specificity and accuracy in finding an intrauterine infection (histologically confirmed): for Leu--93.3%, 25%, and 47.8%, respectively; for CRP--100%, 53.4%, and 69.3%; and IL-6--90%, 70%, and 76.7%, respectively. Obtained results demonstrate that clinical symptoms are rarely indicative of IUI. Of all laboratory measurements, IL-6 has the best diagnostic profile, followed by CRP and leukocyte count.