Balon za sazrijevanje cerviksa maternice u predindukciji porođaja - jednocentrična studija

Cervical ripening can be promoted in many ways, but mechanical methods are among the oldest. Like all other methods, this one also has its pros and cons. Disadvantages compared to pharmacological methods include some maternal discomfort upon manipulation of the cervix, a theoretical increase in the risk of maternal and neonatal infection from the introduction of a foreign body, potential disruption of a low-lying placenta, and increase in the need of oxytocin induction of labor. The aim of the study was to evaluate the effect of using cervical ripening balloon in preinduction on the mode of delivery. This was a longitudinal, cohort, intervention, non-randomized one center study. Inclusion criteria were term pregnancies with gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Preinduction of labor was performed in term pregnancies at Sestre milosrdnice University Hospital Center. Results in the first 150 women having undergone labor preinduction with cervical ripening balloon were included. Two-sided p values <0.05 were considered significant. Statistical analysis was done using SPSS Version 20.0. The study included 150 women; one woman was excluded from further analyses due to conversion of fetal presentation (head to breech). Indications for labor preinduction were as follows: gestational diabetes, oligohydramnios, intrauterine growth restriction, gestational hypertension/preeclampsia and pregnancies after 41 weeks of pregnancy. Women with normal vaginal delivery (96/149) had lower rates of gestational diabetes and oligohydramnios and used epidural analgesia more frequently. Women with dystocia (32/53) had a significantly longer labor duration and higher neonatal birth weight. In multivariate analysis, multiparity, greater cervical dilatation after balloon removal and use of epidural analgesia were associated with a decreased risk of cesarean section, while the presence of gestational diabetes and oligohydramnios was associated with an increased risk of cesarean section. We found this preinduction method safe and efficient, with a potential to increase the rate of vaginal deliveries.Sazrijevanje cerviksa maternice može se poticati na nekoliko načina. Najstarije metode su mehaničke metode koje imaju svojih prednosti i nedostataka. Nedostaci u usporedbi s farmakološkim metodama uključuju određenu majčinsku nelagodu pri manipulaciji cerviksom maternice, povećanje rizika od majčine i neonatalne infekcije zbog unošenja stranog tijela, mogućnost ozljede posteljice niskog sijela i povećanu potrebu za uporabom oksitocina u porođaju. Cilj istraživanja bio je procijeniti učinak korištenja balona na sazrijevanje cerviksa maternice u predindukciji porođaja. Provedena je longitudinalna, kohortna, intervencijska, ne-randomizirana studija. Kriteriji za uključivanje bili su terminske trudnoće s gestacijskim dijabetesom, oligohidramnijem, intrauterinim zastojem u fetalnom rastu, gestacijskom hipertenzijom/preeklampsijom i trudnoća nakon navršenih 41 tjedna trudnoće. Studiju smo provodili kod žena s terminskim trudnoćama u Kliničkom bolničkom centru Sestara milosrdnica. Prikazani su rezultati u prvih 150 trudnica kod kojih je provedena predindukcija porođaja cervikalnim balonom. Vrijednosti p<0,05 smatrale su se značajnima. Statistička analiza provedena je pomoću SPSS Version 20.0. Studija je obuhvatila 150 trudnica, a jedna žena je bila isključena iz daljnjih analiza zbog konverzije fetalnog stava (glave u zadak). Indikacije za predindukciju porođaja su bile: gestacijski dijabetes, oligohidramnij, intrauterini zastoj fetalnog rasta, gestacijska hipertenzija/preeklampsija i trudnoća nakon navršenih 41 tjedna trudnoće. Trudnice koje su rodile vaginalno (96/149) imale su manju učestalost gestacijskog dijabetesa i oligohidramnija i kod njih je češće korištena epiduralna analgezija. Trudnice bez napredovanja porođaja (32/53) imale su značajno duže trajanje porođaja i veću tjelesnu težinu novorođenčeta. U multivarijatnoj analizi su multiparitet, veća dilatacija cerviksa nakon uklanjanja balona i primjena epiduralne analgezije bili povezani sa smanjenim rizikom carskog reza, dok je prisutnost gestacijskog dijabetesa i oligohidramnija bila povezana s povećanim rizikom carskog reza. Smatramo da je ova predindukcijska metoda sigurna, učinkovita i može dovesti do povećanja broja vaginalnih porođaja

Ruptura maternice u trećem trimestru nakon prethodne miomektomije

Rupture of gravid uterus is surgical emergency causing maternal and fetal morbidity and mortality. The risk of uterine rupture is associated with uterine scars caused by previous cesarean section, myomectomy, hysteroscopic procedures, and curettage. We report a case of a 40-year-old woman in 31st week of gestation with spontaneous uterine rupture. It was her third pregnancy. She had two healthy children from previous pregnancies. Her symptoms were abdominal pain, vomiting and pain in the right shoulder lasting for 12 hours prior to admission. Ultrasound examination at admission revealed a dead fetus in the abdomen and free fluid in the abdominal cavity. She had previously undergone laparoscopic myomectomy. After myomectomy, she had one successful vaginal delivery. Every abdominal pain in pregnant woman with uterine scar should be carefully and promptly examined to exclude uterine rupture before further diagnostic procedures. This early time frame is essential for survival of the fetus and sometimes even of the mother. Uterine rupture represents indication for immediate cesarean section and it should be performed within 25 minutes of the first signs of uterine rupture. As shown in the case presented, one successful vaginal delivery after myomectomy is no guarantee for future pregnancies.Ruptura maternice je akutno stanje u porodništvu koje može voditi do majčine i/ili fetalne smrti. Rizik za rupturu maternice povezan je s ožiljkom na maternici uzrokovanim prethodnim carskim rezom, miomektomijom, histeroskopskim zahvatom ili kiretažom. Prikazuje se 40-godišnja trudnica u 31. tjednu trudnoće koja je imala spontanu rupturu maternice. Ovo je bila treća trudnoća ove bolesnice koja je iz ranijih trudnoća rodila dvoje zdrave djece. Simptomi su bili praćeni bolovima u trbuhu, povraćanjem i bolovima u desnom ramenu koji su trajali 12 sati. Ultrazvučnim pregledom kod prijma je nađen mrtav plod u trbušnoj šupljini uz slobodnu tekućinu u abdomenu. Prethodno je bolesnica jedanput imala laparoskopsku miomektomiju. Nakon miomektomije je vaginalno rodila. Svakoj boli u trbuhu kod trudnice s ožiljkom na maternici treba pristupiti pažljivo i hitno pregledati te obraditi kako bi se isključila ruptura maternice prije daljnjih dijagnostičkih postupaka. Ovo rano vrijeme prepoznavanja je ključno za preživljavanje fetusa, a ponekad i majke. Ruptura maternice je indikacija za hitni carski rez koji treba učiniti unutar 25 minuta od prvih znakova rupture maternice. Čak niti jedan uspješan porod nakon stanja poslije miomektomije ne jamči da će ožiljak izdržati drugu trudnoću

Ishod trudnoće uz gestacijski dijabetes u usporedbi s indeksom tjelesne mase

Gestational diabetes involves disorder of glucose metabolism first diagnosed in pregnancy. Obese women undoubtedly have more often complications in reproductive age, such as fertility difficulties, spontaneous and recurrent miscarriages, premature births, and various obstetric and surgical complications related to the course of pregnancy, delivery and puerperium. Children of obese pregnant women are more likely to develop obesity in childhood and adulthood. We analyzed the outcome of 51 pregnancies in obese pregnant women and 50 pregnant women with normal body mass index. All women in both groups were diagnosed with gestational diabetes by the IADPSG criteria. We analyzed gestational age at delivery and mode of delivery, gestational weight gain, presence of concomitant diagnosis of gestational or chronic hypertension, difference in birth weight, and prevalence of hypertrophic newborns. There was no significant difference in gestational age at pregnancy termination and in the mode of delivery. There was a significant difference in gestational weight gain, number of pregnant women with hypertension, neonatal birth weight and number of hypertrophic children. Based on the data presented, we conclude that obesity is an unfavorable factor for pregnancy outcome. It also influences birth weight and fetal hypertrophy, as well as gestational weight gain.Gestacijski dijabetes podrazumijeva poremećaj metabolizma glukoze koji se prvi puta dijagnosticira u trudnoći, a njegova incidencija je u porastu. Pretile žene nedvojbeno imaju češće probleme i komplikacije u reproduktivnim godinama, što podrazumijeva teškoće pri zanošenju, spontane i habitualne pobačaje, prijevremene porođaje i različite opstetričke i kirurške komplikacije vezane za tijek trudnoće, porođaja i babinja. Djeca iz takvih trudnoća češće razvijaju pretilost u djetinjstvu kao i u odrasloj dobi. S obzirom na navedeno analizirali smo ishod trudnoća u 51 pretile trudnice i 50 trudnica s urednim indeksom tjelesne mase, pri čemu su sve trudnice (u objema skupinama) imale dijagnozu gestacijskog dijabetesa prema kriterijima IADPSG. Analizirali smo gestacijsku dob, način dovršenja trudnoće, prirast na težini trudnica, prisutnost istodobnih dijagnoza gestacijske ili kronične hipertenzije, razliku u težini novorođenčadi te učestalost hipertrofične novorođenčadi. Rezultati su pokazali da ne postoji statistički značajna razlika u gestacijskoj dobi kad je završena trudnoća niti u načinu dovršenja porođaja. Utvrđena je statistički značajna razlika u dobivenim kilogramima tijekom trudnoće, broju trudnica s hipertenzijom, porođajnoj masi novorođenčadi i broju hipertrofične djece. U zaključku, pretilost u trudnoći s gestacijskim dijabetesom je nepovoljan čimbenik za ishod trudnoće, porođajnu masu i prekomjeran rast novorođenčadi, kao i za prirast tjelesne mase trudnice tijekom trudnoće

Procjena rizika u trudnoćama majki u dobi iznad 40 godina

The objective of this study was to assess the relationship between women’s age and risk of pregnancy-related complications. The study was a retrospective cohort analysis of the pregnancy-related complications and outcomes between two age groups of parturient women. Categorical data were expressed as absolute and relative frequencies. Statistical analysis was performed using χ2-test. The incidence of gestational diabetes was higher in the 40-47 age group as compared with the 20-24 age group. The rates of hypertension, preeclampsia, intrahepatic cholestasis of pregnancy and hypothyroidism did not differ between the two groups. The rates of labor induction, oxytocin use, vaginal delivery, and need for episiotomy were higher in younger age group. Dystocia and breech presentation as indications for cesarean section were more common among younger women. According to study results, the risk of gestational diabetes and rates of cesarean delivery increased with advanced maternal age.Cilj istraživanja bio je ispitati povezanost dobi majke i rizika povezanih s njihovim trudnoćama. Retrospektivno kohortno istraživanje provedeno je usporedbom pojavnosti rizika i ishoda trudnoća dviju skupina trudnica. Kategorijski podatci prikazani su apsolutnim i relativnim frekvencijama. Statistička analiza provedena je primjenom χ2-testa. Incidencija gestacijskog dijabetesa bila je veća u skupini trudnica u dobi od 40-47 godina u usporedbi sa skupinom u dobi od 20-24 godine. Stopa hipertenzije, preeklampsije, intrahepatične kolestaze u trudnoći i hipotireoidizma nije se razlikovala između dviju dobnih skupina trudnica. Stope indukcije porođaja, upotrebe oksitocina, vaginalnog porođaja i potreba za epiziotomijom bile su veće u trudnica mlađe dobi. Nenapredovanje porođaja i stav ploda zatkom kao indikacije za carski rez bile su češće u žena mlađe dobi. Rezultati istraživanja upućuju na veći rizik gestacijskog dijabetesa i dovršenja trudnoće carskim rezom u trudnica uznapredovale životne dobi

Utječu li novi dijagnostički kriteriji za gestacijski dijabetes na ishod trudnoća?

The incidence of pregnancy related diabetes has been steadily increasing during the past decade. The aim of this retrospective study was to evaluate the type and prevalence of gestational diabetes complications after implementing new diagnostic criteria for gestational diabetes. The incidence of gestational diabetes, maternal age, mode of delivery and birth weight were analyzed. Study patients were divided into three groups. The first group consisted of patients who gave birth during 2005, the second group during 2011 and the third group during 2012. In 2005, the World Health Organization criteria were used on diagnosing gestational diabetes, whereas in 2011 and 2012 the criteria issued by the International Association of Diabetes and Pregnancy Study Groups were considered. Th ere was no statistically significant difference among the groups according to maternal age, birth weight (p=0.203) and mode of delivery (p=0.883). Cesarean section was performed in about 30% of deliveries in all groups combined. There was no significant difference in the number of neonatal hypertrophy (p=0.348), although the distribution of hypertrophy showed a tendency towards higher values in 2005. Th e incidence of gestational diabetes was 2.2% in 2005, 6.6% in 2011 and 12% in 2012. In conclusion, difference in the incidence of pregnancy related diabetes appeared to have resulted directly from using different diagnostic criteria. The new criteria contributed to a relatively higher incidence of gestational diabetes but also achieved better gestational glycemic control and consequently better fetal growth regulation.Incidencija gestacijskog dijabetesa je u stalnom porastu u proteklom desetljeću. Cilj ove retrospektivne studije bio je utvrditi komplikacije gestacijskog dijabetesa i ishode trudnoća nakon promjene kriterija za dijagnozu gestacijskog dijebetesa. Analizirana je incidencija dijabetesa u trudnoći, dob majki, način dovršenja porođaja i težina novorođenčadi. Ispitanice su bile podijeljene u tri skupine. U prvoj skupini su bile žene koje su rodile u 2005. godini, u drugoj skupini one koje su rodile 2011. godine, a u trećoj skupini one koje su rodile 2012. godine. Za dijagnozu gestacijskog dijabetesa 2005. godine korišteni su kriteriji Svjetske zdravstvene organizacije, a 2011. i 2012. godine kriteriji IADPSG (International Association of Diabetes and Pregnancy Study Groups). U ispitivanim skupinama nije nađena statistički značajna razlika s obzirom na dob rodilja. Nije bilo statistički značajne razlike u prosječnoj težini novorođenčadi (p=0,203) među ispitivanim skupinama. Također nije nađena statistički značajna razlika niti u načinu dovršenja porođaja (p=0,883). U ispitivanom uzorku carskim rezom rodilo je oko 30% trudnica. Nije bilo statistički značajne razlike u pojavnosti fetalne hipertrofije (p=0,348), ali je 2005. godine rođeno više djece u skupinama s većom porođajnom masom. Godine 2005. incidencija gestacijskog dijabetesa bila je 2,2%, 2011. godine 6,6%, a 2012. godine 12%. Razlika u incidenciji gestacijskog dijabetesa posljedica je primjene različitih dijagnostičkih kriterija. Novi kriteriji su doprinijeli porastu incidencije gestacijskog dijabetesa, ali i boljoj regulaciji glikemije te posljedično boljoj regulaciji fetalnoga rasta

Epiduralna analgezija u porodništvu - proturječja

Labor pain is one of the most severe pains. Labor is a complex and individual process with varying maternal requesting analgesia. Labor analgesia must be safe and accompanied by minimal amount of unwanted consequences for both the mother and the child, as well as for the delivery procedure. Epidural analgesia is the treatment that best meets these demands. According to the American Congress of Obstetrics and Gynecology and American Society of Anesthesiologists, mother’s demand is a reason enough for the introduction of epidural analgesia in labor, providing that no contraindications exist. The application of analgesics should not cease at the end of the second stage of labor, but it is recommended that lower concentration analgesics be then applied. Based on the latest studies, it can be claimed that epidural analgesia can be applied during the major part of the first and second stage of labor. According to previous investigations, there is no definitive conclusion about the incidence of instrumental delivery, duration of second stage of labor, time of epidural analgesia initiation, and long term outcomes for the newborn. Cooperation of obstetric and anesthesiology personnel, as well as appropriate technical equipment significantly decrease the need of instrumental completion of a delivery, as well as other complications encountered in the application of epidural analgesia. Our hospital offers 24/7 epidural analgesia service. The majority of pregnant women in our hospital were aware of the advantages of epidural analgesia for labor, however, only a small proportion of them used it, mainly because of inadequate level of information.Bol kod porođaja smatra se jednom od najjačih boli. Porođaj je složen i individualan proces s različitim željama žena za analgezijom. Analgezija u porođaju mora biti sigurna i s minimalnim neželjenim posljedicama za majku, dijete i za tijek porođaja. Tim uvjetima najbolje udovoljava epiduralna analgezija (EA). Prema American College of Obstetrics and Gynecology i American Society of Anesthesiologists za primjenu EA u porođaju dovoljna je želja rodilje ako ne postoji kontraindikacija. Davanje analgetika ne treba prestati na kraju drugog porođajnog doba, ali se tada preporučuju niske koncentracije lokalnog anestetika te dodavanje adjuvansa. Novije studije ukazuju na to da se EA može primijeniti u najvećem dijelu prvog i drugog porođajnog doba. Bez obzira na dosadašnja iskustva i istraživanja ne postoji slaganje oko učestalosti instrumentalnog dovršenja porođaja, trajanja drugog porođajnog doba uz EA i vremena uvođenja EA te dugoročnog utjecaja na dijete. Dobra suradnja opstetričkog i anesteziološkog osoblja i dobra tehnička opremljenost znatno smanjuju potrebu za instrumentalnim dovršenjem porođaja, kao i druge komplikacije EA. Naša bolnica nudi EA za olakšani porođaj tijekom 24 sata. Većina trudnica je svjesna prednosti primjene EA za vaginalni porođaj, međutim, samo mali broj trudnica iskoristi tu mogućnost, uglavnom zbog nedovoljne obaviještenosti o toj metodi

The impact of temporal variability of biochemical markers PAPP-A and free β-hCG on the specificity of the first-trimester Down syndrome screening: a Croatian retrospective study

<p>Abstract</p> <p>Background</p> <p>The variability of maternal serum biochemical markers for Down syndrome, free β-hCG and PAPP-A can have a different impact on false-positive rates between the 10+0 and 13+6 week of gestation. The study population comprised 2883 unaffected, singleton, spontaneously conceived pregnancies in Croatian women, who delivered apparently healthy child at term. Women were separated in 4 groups, dependently on the gestational week when the analyses of biochemical markers were performed. The concentrations of free β-hCG and PAPP-A in maternal serum were determined by solid-phase, enzyme-labeled chemiluminiscent immunometric assay (Siemens Immulite). Concentrations were converted to MoMs, according to centre-specific weighted regression median curves for both markers in unaffected pregnancies. The individual risks for trisomies 21, 18 and 13 were computed by Prisca 4.0 software.</p> <p>Findings</p> <p>There were no significant differences between the sub-groups, regarding maternal age, maternal weight and the proportion of smokers. The difference in log₁₀MoM free β-hCG values, between the 11^thand 12^thgestational week, was significant (p = 0.002). The difference in log₁₀MoM PAPP-A values between the 11^thand 12^th, and between 12^thand 13^thweek of gestation was significant (p = 0.006 and p = 0.003, respectively). False-positive rates of biochemical risk for trisomies were 16.1% before the 11^thweek, 12.8% in week 12^th, 11.9% in week 13^thand 9.9% after week 13^th. The differences were not statistically significant.</p> <p>Conclusions</p> <p>Biochemical markers (log₁₀MoMs) showed gestation related variations in the first-trimester unaffected pregnancies, although the variations could not be attributed either to the inaccuracy of analytical procedures or to the inappropriately settled curves of median values for the first-trimester biochemical markers.</p

COMBINED ULTRASOUND AND BIOCHEMICAL SCREENING FOR FETAL ANEUPLOIDY AT 10 – 14 WEEKS OF PREGNANCY: FIRST RESULTS OF TEST PERFORMANCE IN CROATIA

Sažetak. Cilj rada. Retrospektivna studija nakon primjene kombiniranog ultrazvučno-biokemijskog testa probira trisomija u prvom tromjesečju trudnoće. Metode. Od veljače 2006. do srpnja 2008. godine probir je učinjen u 1112 trudnica između 10. i 14. tjedna trudnoće. Individualni rizik trisomije 21, 18 i 13 izračunavali smo kombinacijom dobnog rizika trudnice, ultrazvučnih biljega u ploda (debljina nuhalnog nabora – NT, udaljenosti tjeme-trtica – CRL) te biokemijskih biljega u serumu trudnice (slobodni -hCG i PAPP-A), pomoću licenciranog računalnog programa (Typolog). Koncentracije biokemijskih biljega smo određivali imunometrijskom kemiluminiscentnom metodom (IMMULITE). Biokemijske biljege, kao i NT u odnosu na CRL, izrazili smo u obliku višekratnika MoM, u odnosu na dnevne regresijske medijane za odgovarajuću gestaciju u neugroženim trudnoćama. Rezultate smo obradili nakon dovršenih svih ispitanih trudnoća. Ukupno su 62 testirane trudnice imale povećani kombinirani rizik trisomije 21, od kojih je 10 trudnica imalo i povećani rizik trisomije 18/13. Četiri trisomije 21 i jedna trisomija 18 otkrivene su prenatalnom dijagnozom; stopa detekcije bila je 100% (5/5). U trudnica s povećanim rizikom u probiru učinjeno je 7 biopsija koriona i 38 ranih amniocenteza. Udio lažno-pozitivnih rezultata bio je 5.1%. Zaključak. Prvi rezultati provođenja kombiniranog probirnog testa u Hrvatskoj potvrdili su visoku osjetljivost i veću specifičnost, u poredbi s biokemijskim probirnim testom u drugom tromjesečju trudnoće.Objective. Retrospective study of the results of the first-trimester combined screening for fetal trisomies with ultrasound and biochemical markers. Methods. In the period from February 2006 to July 2008, a total of 1112 pregnant-women underwent screening between the 10th and 14th gestational week. Individual risk for trisomies 21, 18 and 13, combining maternal age, ultrasonography (nuchal translucency, crown-rump length) and serum biochemical analytes (free -hCG, PAPP-A) was computed by means of licensed Typolog software. Concentrations of biochemical markers were determined by chemiluminiscent immunometric assay (IMMULITE). Both biochemical markers, as well as NT, were expressed as Multiples of the Median (MoM), based on the regressed medians of the corresponding gestational age in unaffected pregnancies. Results. All studied pregnancies were followed up to term. A total of 62 pregnant women were categorized as high-risk for trisomy 21, and 10 of them had also an elevated risk for trisomies 18/13, respectively. Four trisomies 21 and one trisomy 18 were detected through combined test and confirmed with prenatal diagnostic procedure. Detection rate was 100%. In those with high risk, 7 chorionic villi sampling and 38 amniocenteses were performed. False-positive rate was 5.1%. Conclusion. The results of the first-trimester screening in Croatia confirmed high sensitivity and better specificity of the combined ultrasonic and biochemical markers, in relation with the second-trimester biochemical screening test