Raised electrical uterine activity and shortened cervical length could predict preterm delivery in a low-risk population

PURPOSE: To compare diagnostic accuracy of sonographic cervical length (CL) measurement and uterine electric activity assessed by electromyography (EMG) in second trimester regarding prediction of preterm delivery (PTD). ----- METHODS: Prospective study of 308 low-risk women. Shortened CL was defined as ≤25 mm (≤5th centile), while raised EMG activity was defined as the presence of ≥20 action potentials in 20 min of assessment (≥95th centile). Outcome measures were diagnostic accuracy of both tests alone or in combination for prediction of PTD and early PTD (≤34 weeks). ----- RESULTS: The incidence of PTD was 23/308 (7.4%) while the incidence of early PTD was 9/308 (2.9%). Shortened CL and raised EMG activity were significantly related to PTD [prevalence-weighted likelihood ratio (pw-LR) 1.9, 95% CI 1.0-3.5 vs. 9.5, 95% CI 2.5-35.7], but not to early PTD (pw-LR 0.4, 95% CI 0.2-0.8 vs. 0.6, 95% CI 0.3-1.7). Significant predictive value for early PTD was found only if both tests were combined (pw-LR 4, 95% CI 1.3-14.3). ----- CONCLUSION: Shortened CL and raised EMG activity in second trimester have significant diagnostic accuracy regarding prediction of PTD in a low-risk population. However, in order to be useful as a predictor for early PTD both tests must be positive

VACCINATION AS PRIMARY PREVENTION OF THE HUMAN PAPILLOMAVIRUS INFECTION

Problem infekcije humanim papiloma virusom (HPV) kroz njezinu rasprostranjenost, načine prenošenja te potencijalne dugoročne posljedice – karcinom cerviksa, poznat je već godinama. Sekundarna prevencija karcinoma cerviksa kroz programe probira citološkom analizom po Papanicolau, uspjela je u velikom dijelu svijeta smanjiti posljedice perzistirajuće HPV infekcije. Međutim, unatoč napretku u metodama probira i liječenja preinvazivnih oblika i dalje se javlja veliki broj novootkrivenih slučajeva karcinoma cerviksa svih stadija. Dosadašnje metode liječenja HPV infekcije nisu se pokazale učinkovitima te bi moguće rješenje smanjenja učestalosti karcinoma bilo u primarnoj prevenciji. Primarnom prevencijom, odnosno HPV imunizacijom, za očekivati je smanjenje učestalosti i posljedica HPV infekcije. Sa ciljem toga dvije su farmaceutske kompanije razvile profilaktičko cjepivo kao oblik imunizacije protiv HPV infekcije nekim od tipova virusa. Jedno od njih dostupno je u Europi, Americi i brojnim drugim zemljama. U ovome pregledu, prikazani su do sada objavljeni rezultati oba cjepiva s posebnim osvrtom na registrirano, kvadrivalentno cjepivo (tipovi 6, 11, 16 i 18). Cjepivo svojom učinkovitošću od 90% za perzistirajuću infekciju te učinkovitošću od 100% u prevenciji posljedice HPV infekcija na ciljne organe anogenitalne regije, u periodu od 5 godina, daje ohrabrujuće rezultate za rutinsku primjenu u općoj populaciji.Human papilloma virus (HPV) infection is well defined and well known problem all around the world, mostly through its easy spreadness, acquisition and potential long term effects related to cervical cancer. Secondary ¬prevention of cervical cancer is defined through routine cytology screening programmes, but despite all efforts, there are several thousands of cervical cancer new cases diagnosed annually worldwide. The relationship between cervical cancer and HPV infection is already well known. Presently available methods for HPV treatment are not satisfactory and the possible solution is in primary prevention. Primary prevention or immunization against HPV infection may reduce the incidence and consequences of HPV infection on the long terms. Today, two pharmaceutical companies developed prophylactic HPV vaccine. One of them is already readily available in USA, EU and numerous other countries. In this review, we present the results of their clinical efficacy with the point on already registered and available quadrivalent prophylactic HPV vaccine (types 6, 11, 16 and 18). With more than 90% effectiveness in the preventing persistent infection and 100% effectiveness in the prevention of HPV related genital disease over the 5 years period of time, it gives a promising results for the use in general population

Doppler assessment of uteroplacental blood flow in screening for preeclampsia

Preeclampsia complicates between 4–5 percent of pregnancies and it is one of the leading causes of maternal and perinatal mortality and morbidity worldwide. One potential screening tool for identifying pregnant women at risk for developing pre-eclampsia is Doppler assessment of blood flow in uterine arteries (UtA) and some other parts of uteroplacental circulation. Studies suggest that abnormal UtA waveforms (abnormal resistance index (RI), pulsatility index (PI) or diastolic notching) reflects impaired uteroplacental blood flow due to failed second wave of trophoblastic invasion of spiral arteries, and identify women at high risk of developing preeclampsia. Still, due to high false-positive rates, low sensitivity and low positive predictive values the majority of international guidelines do not recommend the use of UtA Doppler in clinical practice. Until more evidence, perinatal care should still focus on taking a detailed medical history, assessing for risk factors and measuring blood pressure at each prenatal visit and if classified as high risk, to use some other screening methods. Also, a growing amount of evidence suggests that pregnant women presenting with one recognized high risk factors or two or more moderate risk factors for developing pre-eclampsia should be offered low-dose aspirin from 12 weeks gestation in order to reduce the risk of developing preeclampsia

TERAPIJA METOTREKSATOM GINEKOLOŠKIH PACIJENTICA: ČETVEROGODIŠNJE ISKUSTVO U TERCIJARNOJ ZDRAVSTVENOJ USTANOVI

Aim: The aim of this study was to present methotrexate treatment results in ectopic pregnancy and gestational trophoblastic neoplasia (GTN) at a tertiary referral center. Methods: A retrospective case-series study was conducted using data from records of patients treated with methotrexate during a 4-year period at Merkur University Hospital in Zagreb, Croatia. The study included 11 patients divided into 2 groups: 6 patients with ectopic pregnancy (5 tubal and 1 cornual) and 5 patients with low-risk GTN. Patients with ectopic pregnancy were treated with single dose methotrexate protocol (1 mg/kg/day intramuscularly), whereas those with low-risk GTN were treated with 8-day single-agent methotrexate along with leucovorin rescue protocol. Results: Among 5 tubal pregnancies, methotrexate treatment was successful in 4 (80%) cases, while one patient required surgical treatment. One case of cornual pregnancy also required surgical treatment after ineffective methotrexate treatment. Of 5 GTN cases treated with methotrexate, 3 required further EMA-CO treatment and 1 required additional surgical treatment, yielding the overall success rate of methotrexate treatment of 20%. Conclusion: Methotrexate is a valuable medication for treatment of appropriately selected ectopic pregnancy cases, while its usefulness and effi ciency in the treatment of low-risk GTN diseases has not been confi rmed.Cilj: Cilj rada je prikazati rezultate liječenja metotreksatom dviju ginekoloških bolesti u tercijarnom referentnom centru. Metode: Provedena je retrospektivna studija uporabom podataka iz povijesti bolesti pacijentica liječenih metotreksatom tijekom četverogodišnjeg razdoblja u Kliničkoj bolnici Merkur, Zagreb, Hrvatska. U studiju je uključeno 11 pacijentica koje su podijeljene u 2 skupine: 6 pacijentica s ektopičnom trudnoćom (5 tubarnih i 1 kornualna) i 5 pacijentica s gestacijskom trofoblastičnom neoplazijom (GTN) niskog rizika. Pacijentice s ektopičnom trudnoćom liječene su jednokratnom dozom metotreksata (1 mg/kg/dan intramuskularno), dok su pacijentice s GTN niskog rizika liječene osmodnevnim protokolom metotreksatom i leukovorinom. Rezultati: Od 5 pacijentica s tubarnom trudnoćom liječenje metotreksatom bilo je uspješno u 4 (80%) slučaja, dok je u 1 slučaju bilo potrebno kirurško liječenje. U 1 zabilježenom slučaju kornualne trudnoće liječenje metotreksatom bilo je neuspješno te je pacijentica zbrinuta kirurški. Od 5 slučajeva GTN liječenih metotreksatom u 3 slučaja bio je potreban nastavak kemoterapije po EMA-CO protokolu, dok je u 1 slučaju bilo potrebno dodatno kirurško liječenje te je ukupna uspješnost liječenja metotreksatom iznosila 20 %. Zaključak: Metotreksat se može smatrati učinkovitom terapijom u liječenju pažljivo odabranih pacijentica s ektopičnom trudnoćom, dok njegova uspješnost u kemoterapijskom liječenju GTN niskog rizika nije potvrđena

TERAPIJA METOTREKSATOM GINEKOLOŠKIH PACIJENTICA: ČETVEROGODIŠNJE ISKUSTVO U TERCIJARNOJ ZDRAVSTVENOJ USTANOVI

Aim: The aim of this study was to present methotrexate treatment results in ectopic pregnancy and gestational trophoblastic neoplasia (GTN) at a tertiary referral center. Methods: A retrospective case-series study was conducted using data from records of patients treated with methotrexate during a 4-year period at Merkur University Hospital in Zagreb, Croatia. The study included 11 patients divided into 2 groups: 6 patients with ectopic pregnancy (5 tubal and 1 cornual) and 5 patients with low-risk GTN. Patients with ectopic pregnancy were treated with single dose methotrexate protocol (1 mg/kg/day intramuscularly), whereas those with low-risk GTN were treated with 8-day single-agent methotrexate along with leucovorin rescue protocol. Results: Among 5 tubal pregnancies, methotrexate treatment was successful in 4 (80%) cases, while one patient required surgical treatment. One case of cornual pregnancy also required surgical treatment after ineffective methotrexate treatment. Of 5 GTN cases treated with methotrexate, 3 required further EMA-CO treatment and 1 required additional surgical treatment, yielding the overall success rate of methotrexate treatment of 20%. Conclusion: Methotrexate is a valuable medication for treatment of appropriately selected ectopic pregnancy cases, while its usefulness and effi ciency in the treatment of low-risk GTN diseases has not been confi rmed.Cilj: Cilj rada je prikazati rezultate liječenja metotreksatom dviju ginekoloških bolesti u tercijarnom referentnom centru. Metode: Provedena je retrospektivna studija uporabom podataka iz povijesti bolesti pacijentica liječenih metotreksatom tijekom četverogodišnjeg razdoblja u Kliničkoj bolnici Merkur, Zagreb, Hrvatska. U studiju je uključeno 11 pacijentica koje su podijeljene u 2 skupine: 6 pacijentica s ektopičnom trudnoćom (5 tubarnih i 1 kornualna) i 5 pacijentica s gestacijskom trofoblastičnom neoplazijom (GTN) niskog rizika. Pacijentice s ektopičnom trudnoćom liječene su jednokratnom dozom metotreksata (1 mg/kg/dan intramuskularno), dok su pacijentice s GTN niskog rizika liječene osmodnevnim protokolom metotreksatom i leukovorinom. Rezultati: Od 5 pacijentica s tubarnom trudnoćom liječenje metotreksatom bilo je uspješno u 4 (80%) slučaja, dok je u 1 slučaju bilo potrebno kirurško liječenje. U 1 zabilježenom slučaju kornualne trudnoće liječenje metotreksatom bilo je neuspješno te je pacijentica zbrinuta kirurški. Od 5 slučajeva GTN liječenih metotreksatom u 3 slučaja bio je potreban nastavak kemoterapije po EMA-CO protokolu, dok je u 1 slučaju bilo potrebno dodatno kirurško liječenje te je ukupna uspješnost liječenja metotreksatom iznosila 20 %. Zaključak: Metotreksat se može smatrati učinkovitom terapijom u liječenju pažljivo odabranih pacijentica s ektopičnom trudnoćom, dok njegova uspješnost u kemoterapijskom liječenju GTN niskog rizika nije potvrđena

Usporedba učinkovitosti vježba za stabilizaciju sakroilijakalnih zglobova s nošenjem potpornog pojasa radi smanjenja simptoma sakroilijakalne disfunkcije u trudnoći [Effectiveness of exercise compared to wearing support belt in order to stabilize the sacroiliac joints and reduce the symptoms of sacroiliac dysfunction in pregnancy]

To determine the effectiveness of exercise as a very important therapeutic intervention to stabilize the sacroiliac joints and the supporting belt in pregnant women with sacroiliac dysfunction. Methods: A randomized controlled study involving 240 patients with sacroiliac dysfunction in pregnancy. The subjects were randomly selected into two groups, 120 in each with 40 per each trimester. The study group carried out the exercise to stabilize the sacroiliac joints 3 times a week for 45 minutes while the control group was wearing a support belt during routine daily activities. After two weeks pain intensity by numerical rating scale and the level of disability during daily activities by Quebec scale were ­assessed. Results: Pain intensity and the degree of disability caused by sacroiliac dysfunction increases from the beginning to the end of pregnancy. There was a statistically significant reduction in pain intensity (P <0.01, P <0.05) and the degree of disability (P <0.01, P <0.05) after both interventions were applied. There was a connection between pain intensity and the degree of disability in the study group (p <0.56). The study group performed significantly better regarding reduction in pain and the degree of disability compared to the control group (P <0.05). Conclusion: Exercise used to stabilize the sacroiliac joints was more effective in stabiliz ation of the sacroiliac joints during pregnancy in women with sacroiliac dysfunction

DOES ROUTINE PATHOLOGY EVALUATION OF UTERINE CONTENT FOLLOWING EVACUATION FOR ABNORMAL EARLY PREGNANCY INFLUENCE FURTHER MANAGEMENT?

U cilju utvrđivanja svrsishodnosti rutinske patohistološke analize kiretmana nakon evakuacije uterusa poradi poremećene rane trudnoće proveli smo retrospektivno istraživanje kojim su obuhvaćene sve pacijentice koje su, tijekom jednogodišnjeg razdoblja, nakon dijagnoze poremećene trudnoće u prvom tromjesečju, imale evakuaciju uterusa kiretažom. Od ukupno 335 bolesnica tijekom godine dana, 312 ih je imalo nalaz patohistološke analize te su uključene u konačnu analizu. U 272 (87,2 %) histopatološkom analizom potvrđeno je tkivo trofoblasta, dok u ostalih 40 (12,8 %) tkiva trofoblasta nije nađeno unatoč uputnoj dijagnozi. U 10 (3,2 %) ispitanica histopatološkom analizom postavljena je dijagnoza gestacijske trofoblastične bolesti na koju se nije sumnjalo prije evakuacije uterusa. Kod jedne je ispitanice (0,3 %) sumnja na gestacijsku trofoblastičnu bolest isključena histopatološkom analizom. Zaključno, rutinska patohistološka analiza kiretmana nakon evakuacije uterusa indicirane poremećenom ranom trudnoćom potencijalno utječe na daljnji tijek liječenja u 16,3 % ispitanica te je unatoč troškovima opravdana u rutinskoj kliničkoj praksi.The aim was to determine usefulness of routine pathologic evaluation of uterine content after uterine evacuation following the diagnosis of abnormal early pregnancy. This retrospective descriptive study performed during a one-year period included all patients diagnosed with abnormal early pregnancy clinically or by ultrasound in the fi rst trimester. All patients had uterine evacuation. During the study period, 335 women were diagnosed with abnormal early pregnancy and referred for uterine evacuation. Pathology results were available for 312 women included in the analysis. In 272 (87.2%) women, trophoblast tissue was found on examination and therefore intrauterine pregnancy was confi rmed. In the remaining 40 patients, trophoblast was not found. In 10 (3.2%) patients, gestational trophoblastic disease was diagnosed, not being suspected on pre-evacuation assessment. In one patient, suspected molar pregnancy was excluded by pathology evaluation. Based on 51/312 (16.3 %) patients where pathology examination of uterine content infl uenced further management and treatment, we believe that routine pathology examination of uterine content after uterine evacuation in the fi rst trimester following abnormal early pregnancy is justifi able in clinical practice

RECENT ADVANCES IN DIAGNOSIS, MANAGEMENT AND PREVENTION OF RH IMMUNISATION

Rh imunizacija kroz hemolitičku bolest fetusa i novorođenčeta (HBFN) najčešći je uzrok fetalne anemije tijekom trudnoće. Amniocenteza je godinama korištena kao metoda probira kroz određivanje OD 450 uz pomoć Lileyeva dijagrama, no u novije je vrijeme zamijenjena neinvazivnim određivanjem maksimalne brzine protoka u središnjoj moždanoj arteriji fetusa. Napredak je postignut i u liječenju HBFN gdje je konzervativno liječenje zamijenjeno intrauterinom intravaskularnom fetalnom transfuzijom. Također, učinjene su brojne promjene u profilaksi bolesti, ponajviše kroz davanje profilaktičkih anti D imunoglobulina svim Rh negativnim trudnicama. Ta tri postupka smanjila su perinatalnu smrtnost i pobol vezan uz HBFN.Rh immunization and hemolytic disease of the fetus and newborn (HDFN) are one of the most common causes of fetal anemia in pregnancy. Traditionally used amniocentesis and determination of OD 450 using Liley diagram is nowadays replaced by measurements of the peak systolic velocity of the blood flow in the middle fetal cerebral artery. Further advances are obtained in the treatment of HDFN where conservative treatment is completely replaced by intrauterine intravascular blood transfusion. As well as that, there is a marked improvement obtained by adapting the prophylactic protocol, with the most important, administration of anti D immunoglobulin to all Rh negative women. These three procedures resulted in reduction of perinatal mortality and morbidity related to HDFN

EFFECTIVENESS OF EXERCISE COMPARED TO WEARING SUPPORT BELT IN ORDER TO STABILIZE THE SACROILIAC JOINTS AND REDUCE THE SYMPTOMS OF SACROILIAC DYSFUNCTION IN PREGNANCY

Odrediti i usporediti učinkovitost vježba kao vrlo važne terapijske intervencije za stabilizaciju sakroilijakalnih zglobova i potpornog pojasa kod sakroilijakalne disfunkcije u trudnoći. Metode: Randomizirana kontrolna studija koja uključuje 240 trudnica sa sakroilijakalnom disfunkcijom u trudnoći. Ispitanice su metodom slučajnog izbora podijeljene u dvije skupine po 120 u svakoj te po 40 u svakome tromjesečju. Ispitivana skupina provodila je vježbe za stabilizaciju sakroilijakalnih zglobova 3 puta na tjedan po 45 minuta, dok je kontrolna skupina nosila potporni pojas tijekom svakodnevnih aktivnosti. Nakon dva tjedna procijenjen je intenzitet boli numeričkom skalom za procjenu boli, dok je za procjenu stupnja onesposobljenosti prilikom svakodnevnih aktivnosti upotrijebljena Kvibečka skala. Rezultati: Intenzitet boli i stupanj onesposobljenosti uzrokovani sakroilijakalnom disfunkcijom rastu od početka prema kraju trudnoće. Prisutna je statistička značajnost u smanjenju intenziteta boli (P < 0,01; P < 0,05) i stupnja onesposobljenosti (P < 0,01; P < 0,05) nakon obje primijenjene intervencije. Postoji povezanost intenziteta boli i stupnja onesposobljenosti u ispitivanoj skupini (r < 0,56). Ta je skupina imala statistički značajno veće smanjenje boli i stupnja onesposobljenosti od kontrolne skupine (P < 0,05). Zaključak: Rezultati upućuju na bolju učinkovitost vježba za stabilizaciju sakroilijakalnih zglobova od nošenja potpornog pojasa kod sakroilijakalne disfunkcije u trudnoći, što naglašava ulogu fizioterapeuta kod ovog poremećajaTo determine the effectiveness of exercise as a very important therapeutic intervention to stabilize the sacroiliac joints and the supporting belt in pregnant women with sacroiliac dysfunction. Methods: A randomized controlled study involving 240 patients with sacroiliac dysfunction in pregnancy. The subjects were randomly selected into two groups, 120 in each with 40 per each trimester. The study group carried out the exercise to stabilize the sacroiliac joints 3 times a week for 45 minutes while the control group was wearing a support belt during routine daily activities. After two weeks pain intensity by numerical rating scale and the level of disability during daily activities by Quebec scale were ­assessed. Results: Pain intensity and the degree of disability caused by sacroiliac dysfunction increases from the beginning to the end of pregnancy. There was a statistically significant reduction in pain intensity (P <0.01, P <0.05) and the degree of disability (P <0.01, P <0.05) after both interventions were applied. There was a connection between pain intensity and the degree of disability in the study group (p <0.56). The study group performed significantly better regarding reduction in pain and the degree of disability compared to the control group (P <0.05). Conclusion: Exercise used to stabilize the sacroiliac joints was more effective in stabiliz ation of the sacroiliac joints during pregnancy in women with sacroiliac dysfunction

Prevalence, risk factors and pregnancy outcomes of women with gestational diabetes in Croatia – a national study

Introduction. Gestational diabetes is a very important obstetrical issue and one of the most frequent metabolic disorders with differing prevalence among various populations. Aim. To determine the prevalence of gestational diabetes in Croatia and to detect main risk factors and adverse pregnancy outcomes associated with gestational diabetes. Methods. This is a cross sectional study performed using data from medical birth certificates collected in 2014 in Croatia. All pregnant women who gave birth in year 2014 were included in the study, excluding those with known diabetes mellitus type I or type II. Results. Among 39.132 deliveries in 2014 incidence of gestational diabetes was 4.67%. Women with gestational diabetes were older, more overweight before pregnancy but gained less weight during pregnancy (all P’s < 0.001). Onset of labour among women with gestational diabetes was less often spontaneous and more often induced. Also, women with gestational diabetes had a signifi cantly lower incidence of vaginal delivery and concomitantly a higher incidence of delivery by caesarean section. Women with gestational diabetes gave birth to infants with higher birth weight, but other neonatal complications were not more often present among neonates of women with gestational diabetes compared to neonates of women without gestational diabetes. Conclusion. Prevalence of gestational diabetes in Croatia based on medical birth certificates is 4.67% and gestational diabetes in Croatia is associated with important risk factors and adverse perinatal outcomes