Phosphorylated IGFBP-1 in predicting successful vaginal delivery in post-term pregnancy.

PURPOSE: To estimate whether phosphorylated IGFBP-1 (phIGFBP-1) in cervical secretion in term and post-term pregnancies can predict spontaneous onset of labor or vaginal delivery. METHODS: A prospective cohort study of 167 women in singleton term and post-term pregnancies, was conducted at 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between 2013 and 2014. phIGFBP-1 test (Actim Partus Medix Biochemica), ultrasound cervix assessment and Bishop score were analyzed in the study group. Spontaneous onset of labor was the primary and vaginal delivery was the secondary outcome. RESULTS: In 32.5 % of patients, spontaneous uterine contractions appeared. 67.5 % of women delivered vaginally, 32.5 % had cesarean section. phIGFBP-1 test predicted spontaneous onset of labor (sensitivity 0.69, specificity of 0.42) and successful vaginal delivery (0.67, 0.48). In the prediction of spontaneous delivery onset ultrasound cervical assessment and phIBFBP-1 had comparable sensitivity and in the prediction of successful vaginal birth all three tests had comparable sensitivity. The time from preinduction to spontaneous onset of delivery was significantly shorter in women with positive phIGFBP-1 test (13.65 ± 6.7 vs 20.75 ± 2.6 h; p = 0.006). CONCLUSION: A test for phIGFBP1 presence might be an additional tool for predicting both spontaneous onset of labor and successful vaginal delivery in post-term pregnancies.

Transfusion-related acute lung injury in a patient diagnosed with hypofibrinogenemia after a cesarean section--case report and review of the literature.

BACKGROUND: Transfusion-related acute lung injury (TRALI) is a rare, but potentially fatal, complication of blood product transfusion, manifesting as acute respiratory distress syndrome. In most cases, TRALI is associated with massive transfusion of fresh frozen plasma and platelets. CASE REPORT: A 38-year-old-woman at 40 weeks gestation was admitted to hospital with spontaneous labor contractions. A cesarean section was performed due to feto-pelvic disproportion and a male infant (Apgar 10) was delivered. After 37 hours low hemoglobin level and growing subfascial hematoma were detected. Urgent relaparotomy was carried out. The blood loss was over 1500 ml and a massive transfusion (6 units of red cell concentrate, 8 units of fresh frozen plasma and 6 units of cryoprecipitate) was necessary. The patient developed symptoms of acute respiratory distress 10 hours after relaparotomy. No pathological findings were shown in echocardiography and ECG. Chest CT revealed pulmonary edema. Low fibrinogen levels were observed in laboratory tests, decreasing in time after transfusion of the blood products to 1.0/L. Oxygen therapy with facial mask was initiated, furosemide was administered and continued for three days until symptom resolution. A series of hematological tests performed after the patient was discharged from hospital confirmed the diagnosis of TRALI and congenital hypofibrinogenemia. CONCLUSION: Congenital hypofibrinogenemia may be responsible for the development of subfascial hematoma, a complication of cesarean section, necessitating relaparotomy. The following massive transfusion of blood products resulted in a potentially fatal complication in a form of TRALI.

Endometrial polyps in female allograft recipients with abnormal bleedings.

INTRODUCTION: Endometrial polyps are a common focal endometrial pathology, with abnormal uterine bleeding (AUB) as a predominant symptom. Although the great majority of cases are benign, premalignancy or malignancy may develop within the polyp. The need for chronic immunosuppressive therapy in solid organ transplanted patients is associated with a significantly increased risk of malignant lesions. AIM OF THE STUDY: Aim of the study was to evaluate the risk of endometrial polyps in solid organ transplanted women with abnormal uterine bleeding. MATERIAL AND METHODS: The retrospective analysis of 125 cases of AUB in allograft recipients and 200 consecutive cases of AUB in patients from the general population was performed. Pathological findings from dilatation and curettage were analyzed and compared between the groups. RESULTS: Endometrial polyps were the only pathological findings in 12% and 21.5% of cases from the study and the control groups, respectively. In each of the groups, one case of endometrial cancer coexisted with an endometrial polyp. If cases of endometrial polyps coexisting with endometrial hyperplasia were taken into account, the rate of endometrial polyps was similar to that observed in the general population (20% vs. 21.5%, respectively). CONCLUSIONS: Chronic immunosuppression, associated with an increased risk of malignancy, does not increase the risk of endometrial polyps among female graft recipients.

Pregnancy after organ transplantation.

Ovarian function with regular menstrual cycles is usually restored in women of reproductive age after solid organ transplantation. The number of pregnancies reported in these patients increases gradually. Pregnancy is always considered high risk, and not properly planned may lead to serious complications. The best for the patient is to conceive in a period of good general health and good stable graft function, after appropriate preparation and not later than five years after transplantation. Immunosuppressive regimen should be modified before conception. Sirolimus and mycophenolate mofetil should be excluded. The blood levels of immunosuppressive agents should be regularly controlled during the whole pregnancy. The rate of successful pregnancies isn approximately 95% in graft recipients. Increased incidence of preterm labor, anemia and intrauterine growth restriction is observed compared with general population. Organ transplantation itself is not an indication for cesarean section and vaginal delivery is recommended as the best for the patient, the graft and the newborn. Breast feeding is believed to be contraindicated in women on immunosuppressive therapy, however no adverse effects were reported in children of graft recipients who decided to breast feed. The rate of congenital malformations in newborns is approximately 3-4% and does not differ from the rate seen in general population. The rate of perinatal deaths decreased beneath 0.8% in recent reports. Jaundice, hyperglycemia and hyperkalemia, observed more frequently in newborns of graft recipients, are mild and in most cases do not have any clinical implications.

Gynecological issues after organ transplantation.

Organ transplantation has become universally accepted treatment of end-stage organ failure. The main problem focuses on preventing the graft from rejection with the use of immunosuppressive agents. High incidence of infection is the most frequent adverse effect of immunosuppressive therapy. Symptoms of inflammation are often reduced in immunosuppressed patients. All invasive diagnostic and therapeutic procedures should be associated with the increase in dose of steroids and prophylactic antibiotics. Ovarian and menstrual function is usually restored in transplanted women. Function of the hypothalamus-pituitary-ovary axis in transplanted women is believed to be normal. Most common abnormal uterine bleeding in graft recipient are: prolonged and profuse menstruation and inter-menstrual bleeding or spotting. Among the underlying diseases are lesions of the uterus (fibroids, endometrial or cervical polyps), infections of sex organs or hormonal disturbances. Higher rate of endometrial hyperplasia (without atypia) is reported in renal graft recipients. Organ transplantation results in the restored fertility thus effective family planning method is necessary in women of reproductive age who do not want to conceive. Vaginal diaphragms are not advised and intrauterine device are contradicted. Observational studies indicate for safety and high rate of acceptance of oral and transdermal hormonal contraception in transplanted women. Over ten-year experiences of HRT administration in graft recipient have proved the benefits of the therapy. Patients after organ transplantation have three to four-fold increased incidence of malignancy compared with general population. All transplant women must undergo regular gynecological screening for premalignant and malignant lesions of sex organs and breast.

Two routes of hormonal replacement therapy in symptomatic menopausal women after kidney transplantation.

OBJECTIVES: The assessment of efficacy and safety of two regimens of hormonal replacement therapy (HRT) in women after kidney transplantation with climacteric symptoms. MATERIAL AND METHODS: Combined transdermal or transdermal-oral hormonal replacement therapy was administered to 86 kidney-transplanted women, aged 31-52 years, with moderate to severe climacteric symptoms in years 1995-2005. The patients underwent follow-up examinations one, three and six months after onset of the therapy and every four months subsequently. Blood pressure, body weight, sex hormone profile, serum parameters of both kidney and liver function, endometrial image in transvaginal sonography and reduction of climacteric symptoms were assessed. RESULTS: The mean time of the therapy was 5.6 years for transdermal-oral regimen (54 patients) and 4.7 years for transdermal regimen (32 patients). Most patients reported reduction of climacteric symptoms and improved life quality after 6 months of HRT. 28% of women discontinued therapy for medical indications, most often due to significant deterioration of liver function. One case of profound vein thrombosis was noted. 21% of women decided to discontinue therapy after the results of the WHI trial had been published. CONCLUSIONS: Hormonal replacement therapy is effective in climacteric symptoms relief and improvement of life quality in kidney transplanted women. Higher rate of side effects observed in that group of patients contributes to the need for frequent, attentive surveillance. Further studies should be conducted to establish the optimal doses and routes of administration of HRT as well as to assess the range of necessary follow-up examinations.

The evaluation of uterine cavity with saline infusion sonohysterography and hysteroscopy in infertile patients.

OBJECTIVES: The preliminary study was performed to evaluate the diagnostic accuracy of saline infusion sonohysterography (SIS) in the detection of intrauterine pathologies in infertile women The SIS findings were compared to the results of two widely used procedures: transvaginal sonography (TVS) and hysteroscopy (HS). MATERIAL AND METHODS: 68 infertile women, aged 27-42 were enrolled in the study. TVS, SIS and diagnostic HS were consecutively performed in every patient. The results of each method were compared. Sensitivity, specificity, positive predictive value and negative predictive values for TVS and SIS were obtained. RESULTS: Intrauterine pathologies were diagnosed in 25% of patients. TVS detected 6 (37.5%) and SIS revealed 11 (87.5%) of 13 intrauterine pathologies finally visualized at diagnostic hysteroscopy. TVS failed to visualize three submucous myomas, one endometrial polyp and two cases of septate uteri. All three cases of intrauterine synechiae were not detected with this method One submucous myoma and one endometrial polyp were not identified with SIS. The study group was, however, too limited to show statistically significant differences in diagnostic accuracy among TVS, SIS and HS. CONCLUSIONS: Saline infusion sonohysterography is simple, sensitive and inexpensive diagnostic method. The procedure is not time-consuming, causes minimal discomfort to the patient and may be performed without anesthesia in office settings. The method may be recommended for the diagnosis of intrauterine pathologies in infertile women.

Menstrual cycle and sex hormone profile in kidney-transplanted women.

OBJECTIVES: End-stage renal failure is associated with amenorrhaea and extremely reduced fertility. After successful kidney transplantation restoration of menstrual function is observed. The aim of the study was to investigate ovarian function and menstrual cycles in kidney-transplanted women of reproductive age. MATERIALS AND METHODS: 55 ovarian cycles in kidney transplanted women, aged 18-40 years, being one to five years after transplantation, were analyzed and compared with 50 cycles of healthy women. The duration of the cycles as well as FSH, LH, estradiol, progesterone, prolactin and testosterone serum concentrations were monitored. Simultaneously the presence of ovulation was evaluated with repeated sonographic examinations. RESULTS: Regular menstrual cycles were observed in 72.7% of kidney transplanted women. The rates of ovulatory cycles were similar in the study group and the control: 65% and 70% respectively. Mean estradiol level in the follicular phase of the cycle was significantly higher in transplant patients (205.9, SD 160.22 vs 135.9 pg/ml, SD 68.34 in the control). Significantly lower levels of progesterone (13.2 ng/ml, SD 14.2 vs 26.7 ng/ml, SD 14.1 in the control) and testosterone were observed in kidney recipients. Other hormonal parameters did not differ significantly between the groups. CONCLUSIONS: The rate of ovulatory cycles in regularly menstruated kidney transplanted patients is similar to that of healthy women. Similar serum FSH, LH and PRL concentrations as well as increased levels of estrogens are observed in kidney graft recipients in comparison to healthy non-recipients. Increased levels of estrogens put that group of patients at risk of gynecological pathologies.

Combined oral contraception in women after renal transplantation.

AIM: To assess safety of combined low-dose oral contraceptives in women after renal transplantation. MATERIAL AND METHODS: Twenty six female renal graft-recipients, aged from 18 to 44 (mean 31 years), who used combined low-dose oral contraceptives after renal transplantation for at least 18 months were enrolled in the study. All patients had stable graft function with mean serum creatinine of 1.3 mg/dl. In 58% of women effective contraception was the mean indication for the therapy, in the remaining group pills were indicated additionally for the development of ovarian cysts and excessive menstrual bleedings. Ethinyl estradiol dose was 20 mug in 73% of cases and 30-35 microg in the remaining group. RESULTS: No case of pregnancy was observed. Contraceptive therapy was discontinued in two cases: for profound vein thrombosis in one and deterioration of liver function in the other case. No side effects of contraceptives were observed in the remaining group of patients within at least 18-month observational period. No case of ovarian cyst was reported. Oral contraceptives were not found to influence body mass index (BMI), mean blood pressure, serum creatinine and biochemical parameters (AST, ALT, total bilirubin, glucose and cholesterol). CONCLUSIONS: Despite the presence of relative contraindications for hormonal drugs (arterial hypertension and deteriorated liver function) in female renal recipients, administration of combined low-dose contraceptive pill should be taken into account as highly effective contraceptive method, that additionally regulates menstrual bleeding patterns, protects from ovarian cysts development and improves life quality of the patient.

[Concentration of bilirubin in the umbilical blood as an indicator of hyperbilirubinemia in newborns]. / Stezenie bilirubiny we krwi pepowinowej jako wskaznik wystapienia hiperbilirubinemii noworodków.

UNLABELLED: The aim of this study was to estimate the correlation between concentration of bilirubin in the umbilical blood and occurrence of icterus in newborns. MATERIAL AND METHOD: The study investigations covered 187 healthy, full-term newborns in good general condition. Newborns with serological incompatibility were not included into the study. In 155 (83%) cases babies were born through natural passages, in 32 (17%) by Caesarean section. The umbilical blood was taken immediately after delivery and the venous blood on the 3rd day of life to determine concentration of bilirubin. The concentration of bilirubin was determined by spectrophotometry. Bilirubin values lower than 12.9 mg% were considered physiological. Hyperbilirubinemia was recognized when the concentration of bilirubin was over 12.9 mg%. Pearson test was used to estimate the correlation between bilirubin value in the umbilical blood and the venous blood. In case when the value of correlation coefficient was statistically significant the linear regression equation was determined. RESULTS: The mean value of total bilirubin in the umbilical blood was 1.30 mg% +/- 0.47 and in venous blood on the 3rd day of life 8.07 mg% +/- 3.08. The value of concentration coefficient between concentration of total bilirubin, unconjugated and conjugated bilirubin was adequately 0.49 (p < 0.001), 0.31 (p<0.005) and 0.5 (p<0.001). No one with umbilical bilirubin concentration lower than 1 mg% developed hyperbilirubinemia. CONCLUSION: The concentration of bilirubin in the umbilical blood can be useful indicator of risk of icterus in newborns. The special care is need for newborns whose concentration of bilirubin in umbilical blood is over 1 mg%.

[Course of twin pregnancies and labors in the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw]. / Przebieg ciazy i porodu w ciazy blizniaczej w materiale i Kliniki Poloznictwa i Ginekologii Akademii Medycznej w Warszawie.

DESIGN: The aim of the study was to analyze the course of twin pregnancies and labors in the I Department of Obstetrics and Gynaecology, Medical University of Warsaw. MATERIALS AND METHODS: 124 cases of multiple pregnancy and labor that occurred in the I Department of Obstetrics and Gynecology within the period from 1994 to 2001 were retrospectively analyzed. RESULTS: The study revealed high risk of premature labor, premature rupture of the membranes (PROM), intrauterine growth retardation (IUGR) and pregnancy induced hypertension (PIH) in twin pregnancy. High incidence of cesarean sections was seen both in premature and at-term labors. Significant differences between the mean birth weight and Apgar score of I and II twin were observed. Differences in condition of the neonates were smaller in the group of twins born by cesarean section. CONCLUSIONS: The higher incidence of both obstetrical complications and cesarean sections is associated with twin pregnancies. An increased obstetrical risk and lower Apgar score are observed in case of vaginal delivery of the second twin. Cesarean section seems to improve obstetric results and diminish the differences in condition between the neonates.

[Disorders of glucose tolerance among women with pregnancy induced hypertension]. / Zaburzenia tolerancji weglowodanów u pacjentek z nadcisniem tetniczym indukowanym ciaza.

OBJECTIVES: Gestational diabetes is observed to coexist with pregnancy induced hypertension. Insulin resistance might be associated with both of these diseases. DESIGN: To assess the association between glucose intolerance and subsequent development of hypertension in pregnancy. MATERIAL AND METHODS: Glucose levels at the time of routine screening for gestational diabetes among 79 women with pregnancy induced hypertension and 79 normotensive women have been compared. RESULTS: Hypertensive women were statistically more often obese, their pregravid BMIs were greater and their pregnancy weight gain was higher. Among hypertensive women gestational diabetes has been more often diagnosed. As compared with normotensive, women developing PIH had significantly higher glucose levels after 50 g and 75 g of glucose load. CONCLUSIONS: Women with pregnancy induced hypertension are at increased risk of gestational diabetes. Even within the normal range, levels of plasma glucose levels were higher among hypertensive women.

Ultrasonography of the brain, abdomen, and heart in neonates born to liver or renal transplant recipient mothers.

BACKGROUND: Pregnancies in graft recipients are associated with increased risk of a number of pathologies. The aim of the study was to analyze results of brain and abdominal ultrasonography and echocardiography (ECHO) in neonates born to liver (LTx) or renal recipients (RTx). MATERIAL/METHODS: The study group consisted of 82 neonates born to transplanted women (46 neonates of liver recipients and 36 neonates of renal recipients), enrolled in a retrospective study. The control group consisted of 74 neonates from the general population. Sonographic examination of the brain was performed to check for the presence of intra-/periventricular hemorrhage (IVH/PVH) according to Papile, and periventricular leukomalacia (PVL).The results of abdominal ultrasonography and 2-dimensional echocardiography (ECHO) were compared between the groups. The immunosuppressive therapy used during pregnancy was also analyzed. RESULTS: No significant differences were observed between the frequency of IVH in LTx and RTx groups and LTx, RTx, and control groups. Abdominal ultrasonography revealed 1 case of suprarenal hemorrhage, 1 case of cystic kidney, and 3 cases of pyelocalyceal system dilatation in the study group. There were no abnormalities in the echocardiography in 97.8% of children born to mothers after LTx and in 94.4% after RTx. There were significant differences in the immunosuppressive therapy between the pregnant women after LTx and RTx. CONCLUSIONS: The risk was not increased in intra-/periventricular hemorrhage and congenital abnormalities of the gastrointestinal tract and heart in neonates of mothers after organ transplantation, regardless of the immunotherapy used, and risk was similar to that of the general population.