Severe preterm preeclampsia - associated posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome which causes non-specific neurological symptoms such as visual impairment (cortical blindness, diplopia, hemianopia), acute headaches, seizures (focal or general tonic-clonic), vomiting, altered mental status, focal neurologic deficit as a complication of preeclampsia. Preeclampsia is a serious complication specific for pregnancy, characterized by hypertension (systolic > 140 mm Hg and/or diastolic > 90 mm Hg) and proteinuria (> 300 mg u 24-h urine sample , > 1 +) at or after 20th week of gestation. It is one of the leading causes of perinatal morbidity and mortality. We present a 38-year-old pregnant woman, gravida 1 para 0 with PRES which was manifested on the second day after delivery by Cesarean section at 32 weeks of gestation with aphasia and blindness caused by severe preeclampsia. We confirmed the diagnosis by MRI which revealed white matter edema in the posterior cerebral area in a symmetric fashion, hyper intense cortical foci in the right occipital lobe and punctiform lesions in the bilateral occipital lobe. We treated her promptly in the intensive care unit (ICU) with antihypertensive and anticonvulsant therapy after which she fully recovered. PRES should always be kept in mind when a patient in the postpartum period develops one of the above symptoms. If timely recognized and promptly treated, full recover usually follows

Management of fetal supraventricular tachyarrhythmia - case report

The conduction system of the fetal heart is defined by the16th week of gestation when it matures and normally produces a regular rhythm and rate between 110 and 160 beats per minute (bpm) for the remainder of the pregnancy. Deviations from these parameters are fetal arrhythmias. They are diagnosed in 2% of unselected pregnancies. They are mostly benign and transient but some of them are persistent and associated with structural defects or can cause heart failure, fetal hydrops and intrauterine death. Routine prenatal care includes screening for fetal arrhythmias in the second and third trimester with fetal ultrasound examinations which include a view of the four cardiac chambers and both ventricular outflow tracts. The fetal outcomes are improved upon appropriate antepartum diagnosis and care. Here we present a pregnancy and multidisciplinary management, prenatal evaluation and intervention with maternal transplacental treatment of a 28-year-old female, gravida II, para II, in 28+5 weeks of gestation with fetal arrhythmia, in tertiary university hospital. She had a history of previous caesarean section, in the 40th week of gestation due to an infection of the synus pylonidalis. We confirmed suspected fetal arrhythmia as supraventricular tachyarrhythmia without fetal hydrops, based on the ultrasound doppler M mode imaging, and started transplacental administration of antiarrhythmyc agent, digoxin. It has been considered the first line agent for treatment of fetal supraventricular tachycardia but higher maternal doses are required to maintain a therapeutic serum level. We converted fetal heartbeat into normal sinus rhythm after three days of administration of digoxin. We continued to monitor the fetus once a week with controlling levels of digoxin and electrolytes in maternal blood until the end of the pregnancy at 38+6 weeks of gestation

Multidisciplinary approach in the management of pregnancy with placenta accreta spectrum disorder - Case report

From the histopathologic perspective Placenta accreta spectrum (PAS) shows the absence of the normal intervening decidua and invasion of the placenta into the myometrium. There is placenta accreta with the chorionic villi attach directly to the surface of the myometrium in the absence of the decidual layer and placenta increta when the chorionic villi penetrate deeply into the myometrium reaching the external layer. There is also placenta percreta where the invasive chorionic villi reach and penetrate through the myometrium to uterine serosa and it is nowadays the most common reason for peripartum hysterectomy (1). Drawing the line between these subtypes is not always easy, especially in the clinical situations when the invasiveness of the placenta is not known before the delivery (2). The maternal and fetal outcomes are improved upon appropriate antepartum diagnosis and care by multidisciplinary experts with experience in PAS treatment (3). Here we present a pregnancy and multidisciplinary delivery management of a 40-year-old female, gravida V, para IV, with history of the three cesarean sections, in 36+2 weeks of gestation in a tertiary academic teaching hospital. We confirmed suspected PAS antenatally based on ultrasound and magnetic resonance imaging (MRI). Preoperative preparation included the ensuring of blood products availability, the use of arterial occlusion balloons to reduce hemorrhage, and the use of double JJ stent to prevent ureteral injuries. We performed a cesarean section with immediate uterine amputation due to severe bleeding, after which the patient fully recovered. If PAS timely suspected and confirmed intraoperatively, the best maternal and neonatal outcome is achieved by the multidisciplinary approach that enables adequate elective procedure

Diskordantni rast u dikorionskih blizanaca i rizik prijevremenog porođaja

The aim was to determine whether discordant twin growth has an impact on preterm birth in dichorionic pregnancies. This retrospective study included dichorionic twin pregnancies in the period from January 1, 2013 to December 31, 2015. The following variables were investigated: maternal age (years), parity, body mass index (kg/m2), week (≤366/7 and ≥37) and mode of delivery (vaginal and cesarean section), birth weight (grams) and Apgar score (≤7, 8-10). Discordant twin growth in dichorionic pregnancies was found to be associated with preterm birth (χ2=4.74; p=0.03) but had no impact on the mode of delivery (χ2=0.119; p=0.73). There was a statistically significant difference in the rate of small for gestational age (SGA) neonates (χ2=16.4556; p=0.000267) and Apgar score (χ2=7.9931; p<0.05) between the study groups. Mode of conception in dichorionic pregnancies was not a risk factor for preterm delivery (χ2=1.417; p=0.23). In conclusion, discordant twin growth in dichorionic pregnancies is a risk factor for preterm delivery and has no impact on the mode of delivery but has an impact on the rate of SGA and Apgar score.Cilj istraživanja je bio ustanoviti ima li diskordantni rast blizanaca u dikorionskim blizanačkim trudnoćama utjecaja na pojavnost prijevremenog porođaja. U studiju su uključene dikorionske blizanačke trudnoće u razdoblju od 1. siječnja 2013. do 31. prosinca 2015. Istraživane varijable su bile majčinska dob (godine), paritet, indeks tjelesne mase (kg/m2), način po-rođaja (vaginalno i carski rez), porođajna masa (grami) i zbroj APGAR (≤7, 8-10). U blizanačkim trudnoćama s diskordantnim rastom bila je veća učestalost prijevremenog porođaja (χ2=4,74; p=0,03), ali nije bilo razlike u načinu dovršetka trudnoće ­između istraživanih skupina (χ2=0,119; p=0,73). Utvrđena je statistički značajna razlika u pojavnosti hipotrofične djece (χ2=16,4556; p=0,000267) i zbroju APGAR (χ2=7,9931; p<0,05) između istraživanih skupina. Način zanošenja u dikorionskim trudnoćama nije bio činitelj rizika za prijevremeni porođaj u istraživanim skupinama (χ2=1,417; p=0,23). Zaključno, diskordantni rast blizanaca u dikorionskim trudnoćama predstavlja činitelj rizika za prijevremeni porođaj, hipotrofiju novorođenčadi i niži zbroj APGAR, ali nema utjecaja na način dovršetka trudnoće

Expression and role of RECK protein and IL-6 in fetal membranes of pregnant women with premature rupture of amniotic fluid in premature pregnancies

Cilj istraživanja je ispitati postoji li povezanost imunohistokemijske ekspresije interleukina 6 i prisutnosti RECK proteina u plodovim ovojima trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 te su imale histološke značajke korioamnionitisa i PPPPO i skupine onih koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Materijali i metode: U istraživanje je uključeno 60 trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 trudnoće. Trudnice su grupirane u dvije skupine po 30 ispitanica. Prvu su činile one u kojoj je histološki dokazan korioamnionitis te koje su imale PPPPO. Drugu skupinu su činile one koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Plodovi ovoji izuzimani su nakon poroda te je na njima, nakon obrade i pripreme, rađena imunohistokemijska ekspresija RECK proteina te IL-6. Imunohistokemijska izražajnost RECK i IL-6 je kategorizirana kao stupanj obojenosti citoplazme i to: 0 - nema obojanosti - ne detektira se; 1 - slaba obojanost; 2 - jaka obojanost. Rezultati: Nije nađena statistički značajna razlika u smislu životne dobi rodilja, trajanja trudnoće, pariteta i indeksa tjelesne mase između rodilja iz istraživanih skupina. U skupini trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 tjedana, te su imale histološke značajke korioamnionitisa uz PPPPO pronašli smo statistički značajno slabiju imunohistokemijsku izražajnost RECK proteina u odnosu na one koje su imale spontani prijevremeni porođaj (χ2=4,29, p=0,04) bez znakova korioamnionitisa. U obje istraživane skupine imunohistokemijska izražajnost IL-6 je bila jaka, ali nije bilo statistički značajne razlike (Fischer egzaktni test=0,61; p>0,05). Zaključak: U kasnim nedonošenim trudnoćama histološki dokazani korioamnonitis povezan s PPPPO ima utjecaja na smanjenu imunohistokemijsku izražajnost RECK proteina u plodovim ovojima, ali nema utjecaja na ekspresiju IL-6.Objective of this research is to find out is there an association between immunohistochemical expression of Interleukin 6 and presence of RECK protein in fetal membranes of women who had late preterm delivery at 34-36+6/7 weeks and had histological features of chorioamnionitis and PPROM and a group of women who had spontaneous premature birth at the same gestational age without histological features of chorioamnionitis. Materials and methods: There have been 60 women who gave birth at gestational age of 34- 36+6/7 . They were divided into two groups (30 pregnant women in each group). In the first group there were women with histological features of chorioamnionitis who also had PPROM. In the second group were women who had spontaneous preterm delivery at the same gestational age without histological features of chorioamnionitis. Fetal membranes had been collected after delivery and after that immunohistochemistry was preformed using monoclonal antibodies against RECK protein and IL-6. The intensity of anti RECK and IL-6 cytoplasmic staining of placental membranes was categorized as: 0 - undetectable; 1 - weak; 2 – strong; according to the protocol of Scheller et al. (104). SPSS version 17.0 was used for statistical analysis. Results: No statistically significant difference has been found in the terms of the age of pregnant women, duration of pregnancy, parity and body mass index between two research groups. In the group of pregnant women who gave birth at gestational age of 34-36 and who had histological characteristics of chorioamnionitis and PPROM we found statistically significant weaker immunohistochemical expressiveness of RECK protein in comparison to those who gave spontaneous premature birth (χ2=4,29, p=0,04). In both research groups immunohistochemical expressiveness of IL-6 was very strong, but with no statistically significant difference (Fischer exact test= 0.61; p>0,05). Conclusion: In fetal membranes of women who had late preterm delivery histologically proven chorioamnionitis has impact on immunohistological expresiveness of RECK protein, but has no impact on the expression of IL-6

Expression and role of RECK protein and IL-6 in fetal membranes of pregnant women with premature rupture of amniotic fluid in premature pregnancies

Cilj istraživanja je ispitati postoji li povezanost imunohistokemijske ekspresije interleukina 6 i prisutnosti RECK proteina u plodovim ovojima trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 te su imale histološke značajke korioamnionitisa i PPPPO i skupine onih koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Materijali i metode: U istraživanje je uključeno 60 trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 trudnoće. Trudnice su grupirane u dvije skupine po 30 ispitanica. Prvu su činile one u kojoj je histološki dokazan korioamnionitis te koje su imale PPPPO. Drugu skupinu su činile one koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Plodovi ovoji izuzimani su nakon poroda te je na njima, nakon obrade i pripreme, rađena imunohistokemijska ekspresija RECK proteina te IL-6. Imunohistokemijska izražajnost RECK i IL-6 je kategorizirana kao stupanj obojenosti citoplazme i to: 0 - nema obojanosti - ne detektira se; 1 - slaba obojanost; 2 - jaka obojanost. Rezultati: Nije nađena statistički značajna razlika u smislu životne dobi rodilja, trajanja trudnoće, pariteta i indeksa tjelesne mase između rodilja iz istraživanih skupina. U skupini trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 tjedana, te su imale histološke značajke korioamnionitisa uz PPPPO pronašli smo statistički značajno slabiju imunohistokemijsku izražajnost RECK proteina u odnosu na one koje su imale spontani prijevremeni porođaj (χ2=4,29, p=0,04) bez znakova korioamnionitisa. U obje istraživane skupine imunohistokemijska izražajnost IL-6 je bila jaka, ali nije bilo statistički značajne razlike (Fischer egzaktni test=0,61; p>0,05). Zaključak: U kasnim nedonošenim trudnoćama histološki dokazani korioamnonitis povezan s PPPPO ima utjecaja na smanjenu imunohistokemijsku izražajnost RECK proteina u plodovim ovojima, ali nema utjecaja na ekspresiju IL-6.Objective of this research is to find out is there an association between immunohistochemical expression of Interleukin 6 and presence of RECK protein in fetal membranes of women who had late preterm delivery at 34-36+6/7 weeks and had histological features of chorioamnionitis and PPROM and a group of women who had spontaneous premature birth at the same gestational age without histological features of chorioamnionitis. Materials and methods: There have been 60 women who gave birth at gestational age of 34- 36+6/7 . They were divided into two groups (30 pregnant women in each group). In the first group there were women with histological features of chorioamnionitis who also had PPROM. In the second group were women who had spontaneous preterm delivery at the same gestational age without histological features of chorioamnionitis. Fetal membranes had been collected after delivery and after that immunohistochemistry was preformed using monoclonal antibodies against RECK protein and IL-6. The intensity of anti RECK and IL-6 cytoplasmic staining of placental membranes was categorized as: 0 - undetectable; 1 - weak; 2 – strong; according to the protocol of Scheller et al. (104). SPSS version 17.0 was used for statistical analysis. Results: No statistically significant difference has been found in the terms of the age of pregnant women, duration of pregnancy, parity and body mass index between two research groups. In the group of pregnant women who gave birth at gestational age of 34-36 and who had histological characteristics of chorioamnionitis and PPROM we found statistically significant weaker immunohistochemical expressiveness of RECK protein in comparison to those who gave spontaneous premature birth (χ2=4,29, p=0,04). In both research groups immunohistochemical expressiveness of IL-6 was very strong, but with no statistically significant difference (Fischer exact test= 0.61; p>0,05). Conclusion: In fetal membranes of women who had late preterm delivery histologically proven chorioamnionitis has impact on immunohistological expresiveness of RECK protein, but has no impact on the expression of IL-6

Expression and role of RECK protein and IL-6 in fetal membranes of pregnant women with premature rupture of amniotic fluid in premature pregnancies

Cilj istraživanja je ispitati postoji li povezanost imunohistokemijske ekspresije interleukina 6 i prisutnosti RECK proteina u plodovim ovojima trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 te su imale histološke značajke korioamnionitisa i PPPPO i skupine onih koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Materijali i metode: U istraživanje je uključeno 60 trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 trudnoće. Trudnice su grupirane u dvije skupine po 30 ispitanica. Prvu su činile one u kojoj je histološki dokazan korioamnionitis te koje su imale PPPPO. Drugu skupinu su činile one koje su imale spontani prijevremeni porod u istoj gestacijskoj dobi bez znakova korioamnionitisa. Plodovi ovoji izuzimani su nakon poroda te je na njima, nakon obrade i pripreme, rađena imunohistokemijska ekspresija RECK proteina te IL-6. Imunohistokemijska izražajnost RECK i IL-6 je kategorizirana kao stupanj obojenosti citoplazme i to: 0 - nema obojanosti - ne detektira se; 1 - slaba obojanost; 2 - jaka obojanost. Rezultati: Nije nađena statistički značajna razlika u smislu životne dobi rodilja, trajanja trudnoće, pariteta i indeksa tjelesne mase između rodilja iz istraživanih skupina. U skupini trudnica koje su rodile u gestacijskoj dobi 34 - 36+6/7 tjedana, te su imale histološke značajke korioamnionitisa uz PPPPO pronašli smo statistički značajno slabiju imunohistokemijsku izražajnost RECK proteina u odnosu na one koje su imale spontani prijevremeni porođaj (χ2=4,29, p=0,04) bez znakova korioamnionitisa. U obje istraživane skupine imunohistokemijska izražajnost IL-6 je bila jaka, ali nije bilo statistički značajne razlike (Fischer egzaktni test=0,61; p>0,05). Zaključak: U kasnim nedonošenim trudnoćama histološki dokazani korioamnonitis povezan s PPPPO ima utjecaja na smanjenu imunohistokemijsku izražajnost RECK proteina u plodovim ovojima, ali nema utjecaja na ekspresiju IL-6.Objective of this research is to find out is there an association between immunohistochemical expression of Interleukin 6 and presence of RECK protein in fetal membranes of women who had late preterm delivery at 34-36+6/7 weeks and had histological features of chorioamnionitis and PPROM and a group of women who had spontaneous premature birth at the same gestational age without histological features of chorioamnionitis. Materials and methods: There have been 60 women who gave birth at gestational age of 34- 36+6/7 . They were divided into two groups (30 pregnant women in each group). In the first group there were women with histological features of chorioamnionitis who also had PPROM. In the second group were women who had spontaneous preterm delivery at the same gestational age without histological features of chorioamnionitis. Fetal membranes had been collected after delivery and after that immunohistochemistry was preformed using monoclonal antibodies against RECK protein and IL-6. The intensity of anti RECK and IL-6 cytoplasmic staining of placental membranes was categorized as: 0 - undetectable; 1 - weak; 2 – strong; according to the protocol of Scheller et al. (104). SPSS version 17.0 was used for statistical analysis. Results: No statistically significant difference has been found in the terms of the age of pregnant women, duration of pregnancy, parity and body mass index between two research groups. In the group of pregnant women who gave birth at gestational age of 34-36 and who had histological characteristics of chorioamnionitis and PPROM we found statistically significant weaker immunohistochemical expressiveness of RECK protein in comparison to those who gave spontaneous premature birth (χ2=4,29, p=0,04). In both research groups immunohistochemical expressiveness of IL-6 was very strong, but with no statistically significant difference (Fischer exact test= 0.61; p>0,05). Conclusion: In fetal membranes of women who had late preterm delivery histologically proven chorioamnionitis has impact on immunohistological expresiveness of RECK protein, but has no impact on the expression of IL-6

Severe preterm preeclampsia - associated posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome which causes non-specific neurological symptoms such as visual impairment (cortical blindness, diplopia, hemianopia), acute headaches, seizures (focal or general tonic-clonic), vomiting, altered mental status, focal neurologic deficit as a complication of preeclampsia. Preeclampsia is a serious complication specific for pregnancy, characterized by hypertension (systolic > 140 mm Hg and/or diastolic > 90 mm Hg) and proteinuria (> 300 mg u 24-h urine sample , > 1 +) at or after 20th week of gestation. It is one of the leading causes of perinatal morbidity and mortality. We present a 38-year-old pregnant woman, gravida 1 para 0 with PRES which was manifested on the second day after delivery by Cesarean section at 32 weeks of gestation with aphasia and blindness caused by severe preeclampsia. We confirmed the diagnosis by MRI which revealed white matter edema in the posterior cerebral area in a symmetric fashion, hyper intense cortical foci in the right occipital lobe and punctiform lesions in the bilateral occipital lobe. We treated her promptly in the intensive care unit (ICU) with antihypertensive and anticonvulsant therapy after which she fully recovered. PRES should always be kept in mind when a patient in the postpartum period develops one of the above symptoms. If timely recognized and promptly treated, full recover usually follows