INFLUENCE OF THE NUMBER OF PREVIOUS CAESAREAN SECTIONS ON LOWER UTERINE SEGMENT STATE

Determining the lower uterine segment (LUS) state before vaginal delivery and after Caesarean section, including pregnant women with more than one Caesarean section, may be an important step towards prevention from still high maternal and neonatal morbidity and mortality that follow uterine rupture. In pregnant women with one or more previous Caesarean sections, ultrasonic measuring of thickness and estimating the LUS integrity can objectively show the state of uterine scars. The aim of this study was to determine the influence of several previous Caesarean sections on the LUS state in term pregnant women. The prospective study included 62 pregnant women with one or more previous Caesarean sections – the examined group, and 50 pregnant women without Caesarean section – the control group, that after the 37th week of pregnancy had undergone the transvaginal ultrasonic measuring of the thickness of the LUS muscular tissue. In 57 pregnant women from the examined group delivered with another Caesarean section, we estimated, intraoperatively, the LUS integrity in the scar area. On the same occasion, in the scar area, the presence of defect – partial or complete was detected. The research pointed out that the average LUS thickness in the examined group – 1.92±0.95mm was statistically significantly lower compared to the control group – 2.68±0.97mm (p<0.001). The average LUS thickness in 52 examined women with one Caesarean section was 1.92±0.97mm, and in 9 women with two Caesarean sections the average thickness was lower – 1.78±0.82mm, which does not represent a statistically significant difference (p=0.85). In one pregnant woman with three Caesarean sections, the LUS thickness was 3.30mm. We registered the total of 13 pregnant women with a defect in the Caesarean section scar area (12 partial and 1 complete defects), in 12 women after one Caesarean section and in 1 woman after two Caesarean sections. The research results show that women with previous Caesarean section have significantly thinner LUS, compared to the group of pregnant women without scars. With the increasing number of previous Caesarean sections, the LUS thickness decreases, but the difference is not statistically significant. Intraoperatively, the presence of certain LUS classes compared to the number of previous Caesarean sections is not significantly different. Furthermore, the increase in the number of Caesarean sections does not involve a statistically significant increase in the frequency of Caesarean section scar defects, which is in accordance with other authors’ results

RECURRENT MICROSCOPIC GRANULOSA CELL TUMOR OF THE OVARY 21 YEARS AFTER INITIAL OPERATION

Granulosa cell tumors of the ovary are rare hormonally active neoplasms characterized by endocrine manifestations, an indolent course, and late relapse. These tumors have preponderance for local spread and extremely late recurrence and high survival rates. Late recurrence can be extensive with initial, clinically undetectable, microscopic granulosa cell tumor of the ovary. Only a small percentage of such tumors metastasize.We report a case of a 71-year-old woman with extensive recurrent granulosa cell tumor of the ovary 21 years after undergoing abdominal hysterectomy and bilateral salpingo-oophorectomy for atypical endometrial hyperplasia. 20 years after the initial treatment, she was well without evidence of the disease. 21 years after the initial treatment, abdominal pain was abrupt followed by unstable vital signs. Under the impression of internal bleeding, immediate laparotomy was performed. Macroscopic examination revealed predominantly cystic mass filled with clotted blood and separated by solid tissue. Biopsy showed granulosa cell tumor of the ovary. A thorough staging surgery included lymph node sampling, partial omentectomy and excision of any suspicion lesions within the abdominal cavity. The final pathologic expertise confirmed malignant granulosa cell tumor of the ovary. At the pathohystological re-expertise of the first operation material, the diagnosis of the initial, microscopic granulosa cell tumor of the ovary was confirmed. By pathological analysis of the second operation material, the diagnosis of malignant granulosa cell tumor of the ovary was confirmed. Autors describe a case of microscopic granulosa cell tumor of the ovary, which recurred 21 years after the original surgery. Late recurrence can be extensive with initial, clinically undetectable, microscopic granulosa cell tumor of the ovary. Patients must be monitored closely after a diagnosis of ovarian granulosa cell tumor, even if the tumor is occult. This case report emphasises the need for long-term follow-up in patients with granulosa cell tumors of the ovary and considers the possibility of recurrence when presented with acute abdomen after conservative treatment

VAGINAL DELIVERY OF GIANT FETUS – SHOULDER DYSTOCIA

Shoulder dystocia (SD) is defined as unpredictable and urgent obstetric complication that happens when the pelvis of a mother is spread sufficiently to deliver fetal head, but insufficiently to deliver fetal shoulders. It is associated with high percentage of maternal and fetal morbidity. Fetal lethality from hypoxia ranges from 2-16%.We observed the case of vaginal delivery in a multiparous woman in the 39th gestational week. Head delivery was performed by using vacuum extraction. Because of the shoulder dystocia, we applied McRoberts’ maneuver with Resnik’s suprapubic pressure and performed one more episiotomy. Since these maneuvers did not give the expected result, we did the aspiration of the upper respiratory paths of the fetus, after which we performed Hibbard’s cord with simultaneous Kristeler’s maneuver. It led to releasing the shoulders and fetal delivery. On delivery, male fetus was 6000 g/60 cm, estimated with Apgar 1. The urgent reanimation was undertaken. After few hours, the baby was transferred to Pediatric Surgical Clinic for further treatment of present pneumotorax and humerus fracture. After many days, the baby being in normal state, was referred to physical rehabilitation treatment. Today, the baby is without sequelae.SD is one of the most difficult, hardly predictable perilous obstetric complications with high percentage of maternal morbidity and fetal morbidity and mortality. It requires caution, training and skills of obstetric-neonatal team. Liberalization of the use of Caesarian section in managing SD decreases the appearance of injuries in both mother and child. However, regardless of very rapid development of perinatology and the use of modern diagnostic-therapeutic protocols, some questions from classical, practical obstetrics remain unanswered

Insulin Resistance and C-reactive Protein in Preeclampsia

Preeclampsia is referred to as the “disease of the theories” because of the multiple hypotheses proposed to explain is occurrence. Despite considerable research, the causes of preeclampsia remain unclear. Preeclampsia is likely to be multifactorial in origin, and recent research has focused on endothelial dysfunction as a central abnormality in preeclampsia. Insulin resistance and inflammation may contribute to the onset of preeclampsia. They could also be correlated. The aim of the study was to evaluate the presence and relationship between insulin resistance and its markers and C-reactive protein as a marker of inflammation. During their third trimester, 17 preeclamptic women and 20 normotensive controls underwent oral glucose tolerance test, basic biochemical analyses and SHBG. Preeclamptic women were more insulin resistant (p=0,004), and they had higher triglycerides levels (p=0,006), uric acid (p=0,002). However, the study groups did not differ in C-reactive protein (CRP), sex hormone-binding globulin (SHBG), high and low-density lipoproteins (HDL-cholesterol and LDL-cholesterol). In multiple regression analysis only SHBG (p=0,014) and triglycer-ides (p=0,003) were associated with insulin sensitivity independently of the body mass index (BMI), weight gain, HDL and LDL, and CRP. Preeclampsia is a state of increased insulin re- sistance, and CRP as the marker of inflammation was not increased in our research, and not associated with established preeclampsia