How to identify pregnant women at risk of pre-eclampsia? — a review of the current literature

Pre-eclampsia remains a major cause of poor perinatal outcome worldwide. As administering acetylsalicylic acid in a high risk population reduces the risk of PE, it is essential to identify women at risk of PE. Several algorithms for PE risk assessment have been developed. They include maternal factors combined with uterine artery pulsatility index, mean arterial pressure, serum pregnancy-associated plasma protein-A, placental growth factor, and serum soluble fms-like tyrosine kinase-1. Beside PE prophylaxis with acetylsalicylic acid, a proper management of women considered at a high risk of PE is essential. The sFlt-1:PlGF ratio between 20 and 34 + 6 weeks may be used to predict a short-term absence of PE or to predict the risk of PE diagnosis within 4 weeks and a significant shortening of the duration of pregnancy associated with it. The sFlt-1:PlGF ratio may be helpful in deciding about hospitalization or choosing the optimal time for corticosteroid administration in women at risk of PE. It may also help to reduce overall healthcare costs

Is fetus able to feel pain?

Abstract On the basis of fetal hormonal and hemodynamic responses to pain related stimuli, neuroanatomy and observations of preterm babies, it was concluded that human fetus is able to feel pain after 24 weeks gestation. However, it is possible that the fetus may feel pain even before that time. With the development of intrauterine diagnostic and therapeutic procedures, it is crucial to provide fetuses undergoing painful procedures not only with anesthesia but also analgesia. The article presents fetal pain research history and its implications for medicine

Czy nadszedł czas na zmiany w badanich przesiewowych w kierunku nosicielstwa GBS?

Group B Streptococcus (GBS) infections remain an important cause of perinatal complications, despite advanced preventive measures. The most common clinical symptoms of early-onset disease, diagnosed in neonates up to 7 days of life, are sepsis and pneumonia. Late-onset disease is diagnosed in children between 7 and 89 days of life and presents also in forms of other infections. As a result of collaborative efforts of clinicians, researchers and many organizations, various recommendations for intrapartum prevention of perinatal GBS disease have been issued so far. Revised 2002 CDC guidelines for the prevention of early-onset GBS disease recommended universal culture-based screening of all pregnant women at 35–37 weeks of gestation to optimize the identification of those who should receive intrapartum antibiotic prophylaxis (IAP). They were customized by the Polish Gynecological Society and applied in Poland as well. As a result of preventive efforts worldwide, global incidence of GBS infections has declined dramatically over the past 15 years. About 10-30% of pregnant women are colonized with Group B Streptococcus. According to the literature, GBS culture at 35 to 37 weeks of gestation has about 95% negative predictive value for the absence of colonization at the time of labor. However, studies reporting early-onset GBS disease in newborns found that about 60 to 80% of all cases occurred in neonates with negative maternal screening during pregnancy. If the only available screening test is vagino-rectal swab during pregnancy, about 7.5% of women with GBS colonization during labor are not administered IAP. It seems optimal to perform routine screening not during pregnancy, but directly before the delivery – preferably at the time of regular uterine contractions or the rupture of membranes. As the screening test should be widely accessible and rapid, the usual microbiological culture is not a suitable option.Recently, new biochemical and genetic methods have become available. Polymerase chain reaction (PCR) and optical immunoassay are candidates for rapid patient intrapartum GBS testing to determine whether women in labor are colonized with GBS. PCR tests have the sensitivity of over 90% with the specificity of 99%, which is about 13% higher than microbiological culture. According to the literature, IAP does not reduce the overall neonatal mortality, mortality due to GBS infection, or due to other bacterial infections. The incidence of early-onset GBS infection was reduced with IAP in comparison to no intrapartum prophylaxis, but there was no difference in late-onset GBS disease occurrence. Besides GBS, IAP may influence maternal and neonatal infections caused by other pathogens. Moreover, it can also induce GBS and no-GBS pathogen resistance to antibiotics. It therefore seems necessary to replace the current type of GBS screening with GBS DNA PCR intrapartal test – a rapid, highly sensitive and specific method of carrier identification – in order to optimize IAP and, eventually, to decrease the rate of early onset GBS disease in neonates.Paciorkowce grupy B (GBS), najczęściej Streptococcus agalactiae, są patogenami odpowiedzialnymi za około 0,34-0,37 zakażeń noworodków na 1000 żywych urodzeń. Wczesne zakażenia (0 – 7 doba życia) to najczęściej posocznica, zapalenie płuc lub opon mózgowo-rdzeniowych, natomiast późne (7 – 89 doba) to posocznica, zapalenie opon mózgowo-rdzeniowych, zapalenia układu oddechowego, pokarmowego, stawów i tkanki łącznej. Nosicielstwo GBS stwierdza się u około 10-30% ciężarnych. Około 60 – 80% zakażeń GBS noworodków dotyczy matek, u których wynik skriningu ciążowego był negatywny. Według rekomendacji Polskiego Towarzystwa Ginekologicznego każdej ciężarnej pomiędzy 35 a 37 tygodniem ciąży należy pobrać wymaz z przedsionka pochwy i odbytu w celu identyfikacji nosicielstwa GBS. Tak prowadzony skrining ciążowy charakteryzuje się jednak wysokimi odsetkami wyników fałszywie pozytywnych i negatywnych, ponieważ status kolonizacji ciężarnej zmienia się w czasie. W przypadku wykrycia kolonizacji oraz kilku wyjątkowych sytuacjach, wyszczególnionych w rekomendacjach, obowiązkowa jest śródporodowa profilaktyka antybiotykowa. Zastosowanie profilaktyki nie zredukowało jednak ogólnej śmiertelności noworodków, ani śmiertelności związanej z zakażeniami GBS, bądź innymi niż GBS. Szerokie stosowanie antybiotyków indukuje oporność GBS (10-20% inwazyjnych szczepów GBS jest oporne na klindamycynę, 25-30% na erytromycynę), jak i innych patogenów. Być może zmiana prowadzonego skriningu na śródporodowe wykrywanie DNA GBS metodą reakcji łańcuchowej polimerazy (PCR) - metodę szybszą, charakteryzującą się wyższą czułością i mniejszym odsetkiem wyników fałszywie negatywnych - pozwoliłaby na optymalizację profilaktyki zakażeń, a docelowo zmniejszenie odsetka wczesnych zakażeń GBS u noworodków

Rapid cervical phIGFBP-1 test in asymptomatic twin pregnancies is inefficient in predicting preterm delivery prior to 34 gestational weeks

Objectives: To assess the effectiveness of a rapid second trimester test for cervical phIGFBP-1 in the prediction of sponta­neous preterm delivery prior to 34 weeks in asymptomatic twin pregnancies. Material and methods: A prospective observational study conducted on 232 twin pregnancies tested for phIGFBP-1 at 20–24 weeks of gestation. 151 patients assessed as asymptomatic, with cervical length > 25 mm at 20–24 weeks were analysed. The primary outcome was the delivery < 34 weeks of gestation. Results: The spontaneous preterm delivery before completing 34 weeks occurred in 23 patients (15.2%), including 9 in dichorionic and 14 in monochorionic pregnancies. The sensitivity of phIGFBP-1 test was 0.39 and specificity 0.63 in predicting delivery before 34 gestational weeks. phIGFBP-1 had a low positive predictive value of 0.16 and high negative predictive value (0.85). Both positive and negative predictive values of delivery < 34 weeks were close to 1. Conclusions: A test for phIGFBP1 presence is not an effective additional tool for predicting preterm delivery before 34 weeks in twin gestation

Affective disorders in the first week after the delivery: prevalence and risk factors

Summary Objectives: The aim of the study was to evaluate the incidence of affective disorders in women 3 to 5 days after childbirth and the influence of sociodemographic, psychiatric and obstetric factors on the prevalence of maternity blues. Material and methods: The study was conducted at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between January and July 2007. 350 women between 3rd and 5th day of puerperium were asked to fill in a questionnaire, designed especially for the purpose of the study, containing10 items from the Edinburgh Postnatal Depression Scale. 344 questionnaires were filled in properly. Results: 132 mothers (38,4%) had an EPDS score ≥10. It has been revealed that low educational level, lack of family support, pregnancy complications and patient’s history of depression had strong influence on postpartum mood. Parity, cesarean delivery, place of residence, occupation, marital status, socioeconomic level, preterm delivery and breast feeding showed no relationship with maternity blues. There were no differences in newborns’ condition according to Apgar scale. Conclusions: Every third mother is at risk of developing maternity blues. The implementation of screening for early postpartum affective disorders seems to be crucial in singling out women at risk of postpartum depression

Affective disorders in the first week after the delivery: prevalence and risk factors

Summary Objectives: The aim of the study was to evaluate the incidence of affective disorders in women 3 to 5 days after childbirth and the influence of sociodemographic, psychiatric and obstetric factors on the prevalence of maternity blues. Material and methods: The study was conducted at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between January and July 2007. 350 women between 3rd and 5th day of puerperium were asked to fill in a questionnaire, designed especially for the purpose of the study, containing10 items from the Edinburgh Postnatal Depression Scale. 344 questionnaires were filled in properly. Results: 132 mothers (38,4%) had an EPDS score ≥10. It has been revealed that low educational level, lack of family support, pregnancy complications and patient’s history of depression had strong influence on postpartum mood. Parity, cesarean delivery, place of residence, occupation, marital status, socioeconomic level, preterm delivery and breast feeding showed no relationship with maternity blues. There were no differences in newborns’ condition according to Apgar scale. Conclusions: Every third mother is at risk of developing maternity blues. The implementation of screening for early postpartum affective disorders seems to be crucial in singling out women at risk of postpartum depression

Olbrzymi mięśniak gładkokomórkowy macicy ze zmianami degeneracyjnymi imitujący raka jajnika – opis przypadku

Leiomyomas are the most common benign uterine tumors. Although 20-40% of all women in reproductive age may have uterine leiomyomas, they are not very common in pregnancy. Only 0.3-2.6% af all pregnant women are diagnosed with leiomyomas. The leiomyomas are symptomatic in 20-50% of all cases. Clinical symptoms are usually excessive or irregular menstrual bleeding, problems resulting from adjacent organs pressure, sterility, miscarriage or problems during the labour. Leiomyomas are known to have estrogen receptors and can demonstrate an extensive growth in high estrogens concentration environment. During the pregnancy they can grow, stay the same size or as well decrease. Rapid leiomyoma’s growth, caused by its transformation into sarcoma, takes place in about 0.1- 0.8% of all cases. In this article we present a case of patient with leiomyoma, which rapid growth, which imitated ovarian tumor. A 40-year old patient was admitted to the 1st Department of Obstretrics and Gynecology, Medical University of Warsaw, in May 2012 because of a large abdominal tumor. She had four vaginal deliveries and one cesarean section. The patients delivered three months before admission. Since the labour she had suffered from dysuria and noticed a quick waits enlargement. On admission the patient was in good general condition, without any stomachache. A giant tumor in her lower and middle abdomen was found. The tumor reached three fingers above the navel. In the ultrasound scan a large solid-cystic the tumor with moderate vascularization was described. It looked like the ovarian neoplasm. The CA-125 plasma concentration was 389,5 IU/ml. After giving a written informed consent the patient had an operation. During the operation a solid-cystic peducled uterine tumor was diagnosed. The diameter of the tumor was about 25 cm. The uterine and uterine appendages had no pathological macroscopic changes. Intraoperative histopathological examination was carried out and revealed mesenchymal tumor without evident polymorphism or mitosis. Because of lack of any signs of malignancy during the operation only the tumor with its peduncle was removed. The patient was discharged in good general condition after three day of postoperative hospitalization. The final histopathological examination revealed leiomyoma with cystic degeneration changes. A small focus of necrosis and extravasation was found. 4 weeks after the operation there were no abnormalities in the gynecological examination and the CA-125 concentration was 27 IU/ml. The presented case illustrates diagnostic difficulties, which may occur when atypical rapid tumor enlargement and its ultrasound image and laboratory tests results imitate ovarian tumor.W pracy przedstawiono opis przypadku pacjentki, u której szybko powiększający się mięśniak nasuwał podejrzenie nowotworu jajnika. 40-letnia pacjentka została przyjęta do Kliniki z powodu wykrycia ogromnego guza jamy brzusznej, który zdiagnozowano trzy miesiące po porodzie drogami natury. Guz opisywany w badaniu ultrasonograficznym jako prawdopodobnie wywodzący się z jajnika, sięgał trzy palce powyżej pępka. W badania laboratoryjnych uwagę zwracało wysokie stężenie antygenu CA-125 w surowicy – 389,5 IU/ml. Podczas operacji stwierdzono lito-torbielowaty guz macicy o średnicy około 25 cm. W badaniu histopatologicznym śródoperacyjnym postawiono rozpoznanie wstępne guza mezenchymalnego, bez wyraźnych cech polimorfizmu i aktywności mitotycznej. Zakres operacji ograniczono do usunięcia guza. W ostatecznym badaniu histopatologicznym rozpoznano mięśniaka gładkokomórkowego ze zmianami zwyrodnieniowymi. Po 4 tygodniach od operacji nie stwierdzono żadnych nieprawidłowości w zakresie narządu rodnego, a stężenie CA-125 wyniosło 27 IU/ml. Przedstawiony opis przypadku mięśniaka uwidacznia trudności diagnostyczne, jakie może sprawiać nietypowy szybki wzrost i wygląd guza w badaniach obrazowych oraz wyniki badań laboratoryjnych, sugerujące nowotwór jajnika

Glassy cell carcinoma szyjki macicy – opis przypadku i przegląd literatury

Abstract Background: Glassy cell carcinoma of the uterine cervix is a rare neoplasm, first described by Gluksman and Cherry in 1956. It is a poorly differentiated adenosquamous carcinoma, comprising about 1-2% of all cervical cancers. Case presentation: We report a case of glassy cell carcinoma of the uterine cervix in 67-year old female, nullipara, diagnosed two months after symptom onset, in IV-B stage of the disease according to the FIGO classification scale. Cervical smear test obtained three years previously was normal. She was offered a palliative antihemorrhagic radiotherapy of the pelvis and palliative chemotherapy with paclitaxel-carboplatin combination. The patient died within six months of diagnosis. Conclusions: We present a case of a rare carcinoma of the uterine cervix with quick progression and poor outcome.Streszczenie Wprowadzenie: Glassy cell carcinoma szyjki macicy jest rzadkim nowotworem, po raz pierwszy opisanym przez Gluksmana i Cherry’ego w 1956 roku, stanowiącym około 1-2 % wszystkich raków szyjki macicy. Jest to nowotwór niskozróżnicowany, wykazujący cechy zarówno struktur gruczołowych, jak i płaskonabłonkowych. Opis przypadku: U 67-letniej kobiety, nieródki, dwa miesiące po pojawieniu się pierwszych objawów, zdiagnozowano glassy cell carcinoma szyjki macicy w stopniu IV-B według FIGO. Wynik poprzedniej cytologii pobranej przed trzema laty był prawidłowy. Pacjentkę poddano paliatywnej radioterapii miednicy mniejszej oraz chemioterapii dwulejkowej palitakselem i karboplatyną. Chora zmarła w ciągu 6 miesięcy od rozpoznania choroby. Wniosek: Przedstawiony przypadek prezentuje gwałtowny przebieg i złe rokowanie charakterystyczne dla tego rzadkiego nowotworu

Iatrogenic and spontaneous late preterm twins – which are at higher risk of neonatal complications?

Objectives: To evaluate data regarding neonatal mortality and short term morbidity among iatrogenic late preterm (ILP) and spontaneous late preterm (SLP) twin births, and to estimate whether medical interventions – induction of labor in this particular context, are associated with better or poorer outcomes. Material and methods: Retrospective analysis of 110 late preterm dichorionic twin pregnancies was performer basing on medical charts data. All twins were delivered in years 2005-2011 at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw. Late preterm twins, defined as those delivered between 34+0-36+6 weeks of gestation, were divided into spontaneous and iatrogenic preterm births. The primary outcomes of the study were various neonatal adverse events, including one of the following per pregnancy: admission to Neonatal Intensive Care Unit (NICU), respiratory disorders (RD) and pneumonia, intraventricular hemorrhage (IVH), sepsis, NEC and jaundice requiring phototherapy. Mann-Whitney U-test and chi-squared test were used and logistic regression performed to calculate odds ratio, with p valu

Czy epidemia cięć cesarskich jest wykładnikiem liberalizacji wskazań?

Introduction: The rate of cesarean sections around the world is steadily rising. The analysis of indications for cesarean section might fi nd the answer to the question whether this trend is a consequence of more liberal indications. Objectives: The aim of the study was to analyze and compare the changes in the indications for cesarean sections (cs) over the years. Material and methods: Data regarding cesarean sections performed at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, were analyzed and compared: 559 cs between the years 2000-2001 (G1) and 663 cs in 2010 (G2). Results: The rate of cs was statistically higher in 2010 (30.1% vs. 29.2%; pWstęp: Odsetek cięć cesarskich na świecie wykazuje tendencję wzrostową. Analiza wskazań do wykonywanych cięć może odpowiedzieć na pytanie, czy jest to konsekwencją liberalizacji i rozszerzenia wskazań do porodu operacyjnego. Cel: Celem pracy było porównanie i analiza zmian we wskazaniach do cięcia cesarskiego na przełomie lat. Materiał i metody: Przeanalizowano i porównano dane dotyczące cięć cesarskich z lat 2000–2001 (559 pacjentek – G1) oraz 2010 (663 pacjentki – G2), wykonanych w I Katedrze i Klinice Położnictwa i Ginekologii Warszawskiego Uniwersytetu Medycznego. Wyniki: Zaobserwowano istotny wzrost odsetka cięć cesarskich na przestrzeni dekady (G1 30,1% vs G2 39,2%;