Epidemiology, prevention and management of early postpartum hemorrhage — a systematic review

Early Postpartum Hemorrhage (EPH) is one of the leading causes of postpartum mortality. It is defined as blood loss of atleast 500 mL after vaginal or 1000 mL following cesarean delivery within 24 hours postpartum. The following paper includesliterature review aimed to estimate the incidence and predictors of early postpartum hemorrhage (EPH). Available preventionand treatment methods were also assessed. The inclusion criteria for the study were met by 52 studies.The exact frequency of EPH in different populations varies from 1.2% to 12.5%. Maternal, pregnancy-associated, laborcorrelatedand sociodemographic risk factors seem to be important predictors of EPH. In these cases appropriate prophylaxisshould be considered. However, EPH may occur without previous risk factors. The main reason for EPH is uterine atonywhich contributes to up to 80% of cases of postpartum hemorrhage (PPH). Other common reasons for PPH include genitaltract injuries, placenta accreta or coagulopathies. Interestingly, the majority of uterotonics seem to have a similar effect.However, carbetocin seems to be the most effective in certain situations.Appropriate diagnosis of EPH is the most important issue. The treatment should be causative. The first-line treatment shouldinclude uterotonics. Surgical interventions, if required, should be performed without delay, although preoperative uterinetamponade should be considered due to its high effectiveness.Medical staff training in medical simulation centers is an important factor that improves the outcomes of EPH treatment.It provides adaptation to hospital protocols, team work improvement, self-confidence building, more accurate blood lossevaluation and reduced perception of stress. The implementation of systematic trainings provides better outcomes in the future

The comparison of two different embryo culture methods in the course of in vitro fertilization program.

The objective of the study was to compare two different embryo culture methods in the course of in vitro fertilization program by means of fertilization rate, embryo development, total time and cost. 98 patients undergoing assisted reproduction procedures due to infertility were analyzed. The inclusion criteria for the study: first IVF-ET program, at least 10 MII oocytes, no indications for ICSI. Oocytes were divided into two study groups: group A- open culture (oocytes placed in four-well dishes together, then inseminated and cultured in successive wells) and group B - a closed culture (oocytes placed in microdroplets, each embryo cultured separately). The fertilization rate was assessed around 18 hours from insemination. The embryos were classified into four classes. The best embryos were chosen for transfer. In the group A the fertilization rate obtained was lower than in group B (68% vs. 78%, respectively). The microdroplet culture required more time on the insemination day and on the second day of culture, while the four-well dish method required more time on the first day of culture and on the day of transfer. On analyzing the total cost of the above procedures (MI medium and oil costs) it occurred that the microdroplet culture was more expensive than the four-well dish method (due to the intake of paraffin oil). However, the difference was of no practical importance. In the conclusion, microdroplet culture gives a higher fertilization rate than four-well dish culture, probably due to a homogenous sperm distribution. Despite the differences in time outside the incubator and laboratory expenses (which are after all insignificant) microdroplet culture allows a better control over the embryo development. The embryos of best developmental potential can therefore be chosen for ET

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

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

Niewydolność szyjki macicy u pacjentki w ciąży bliźniaczej jednokosmówkowej jednoowodniowej skutecznie leczona szwem szyjkowym ratunkowym i pessarium – opis przypadku i przegląd piśmiennictwa

A monochorionic monoamniotic (MCMA) twin pregnancy is the rarest form of twin gestation, accounting for around 1:10000 to 1:20000 of all deliveries regardless of the region of the world. All multiple gestations have a higher risk of preterm delivery due to either preterm uterine contractions or asymptomatic cervical shortening (cervical incompetence). A case of a 28-year-old primigravida in MCMA twin pregnancy with cervical incompetence diagnosed at 22 weeks of gestation is presented. After obtaining cervical swabs, negative laboratory infection parameters and confirming concordant gestational age on ultrasound scan with no structural abnormalities of both fetuses, the patient was qualified for an emergency cervical cerclage according to Wurm-Hefner method. Five days after the procedure, a cervical pessary was additionally inserted. She was administered antibiotics and steroids. The wellbeing of both fetuses was strictly monitored by means of cardiotocography tracing and ultrasound examinations, on which they were both eutrophic, with no abnormalities in Doppler blood flow patterns. Spontaneous premature rupture of membranes took place at 32 weeks of gestation, a cesarean section was performed and two female fetuses of 1740g and 1760g were delivered. They both required antibiotics because of congenital pneumonia, but no respiratory support was necessary. The twins were discharged from the hospital 22 days after birth in good general condition. This case of a rescue cervical cerclage and pessary used simultaneously can be an example of an effective method of cervical incompetence treatment in twin pregnancies.Ciąża bliźniacza jednokosmówkowa jednoowodniowa (JKJO) jest najrzadszym wariantem ciąży bliźniaczej. Porody ciąż jednoowodniowych stanowią około 1:10000 do 1:20000 wszystkich porodów niezależnie od regionu świata. Ciąże mnogie obarczone są wyższym ryzykiem porodu przedwczesnego w mechanizmie przedwczesnej czynności skurczowej macicy lub bezobjawowego skracania i niewydolności cieśniowo-szyjkowej. Przedstawiono przypadek 28-letniej pierwiastki w ciąży bliźniaczej JKJO, u której zdiagnozowano niewydolność cieśniowo-szyjkową w 22. tygodniu ciąży. Po pobraniu posiewów z kanału szyjki macicy oraz uzyskaniu negatywnych wykładnikow stanu zapalnego, pacjentkę zakwalifikowano do założenia ratunkowego szwu szyjkowego metodą Wurm-Hefnera. Pięć dni po operacji dodatkowo założono pessar szyjkowy. Zastosowano antybiotykoterapię oraz sterydoterapię. Dobrostan obu płodów ściśle monitorowano przy użyciu kardiotokografii oraz badań ultrasonograficznych, w których potwierdzono prawidłowy rozwój płodów oraz brak odchyleń w badaniach dopplerowskich. W 32. tygodniu ciąży samoistnie odpłynął płyn owodniowy. Pacjentkę rozwiązano cięciem cesarskim. Urodzono dwa noworodki płci żeńskiej o masie 1740g oraz 1760g, które wymagały antybiotykoterapii z powodu wrodzonego zapalenia płuc. Niemniej jednak nie wymagały żadnego wsparcia oddechowego. Bliźnięta wypisano do domu 22 dni po porodzie w stanie ogólnym dobrym. Prezentowany przypadek zastosowania szwu szyjkowego ratunkowego oraz pessarium może stanowić przykład skutecznej metody leczenia niewydolności cieśniowoszyjkowej w ciąży bliźniaczej

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

Robotic surgery in gynecology

Introduction of robotic surgery in the first decade of the 21 century was one of the biggest breakthroughs in surgery since the introduction of anesthesia. For the first time in history the surgeon was placed remotely from the patient and was able to operate with the device that has more degrees of freedom than human hand. Initially developed for the US Military in order to allow surgeons to be removed from the battlefield, surgical robots quickly made a leap to the mainstream medicine. One of the first surgical uses for the robot was cardiac surgery, but it is urology and prostate surgery that gave it a widespread popularity. Gynecologic surgeons caught on very quickly and it is estimated that 31% of hysterectomies done in the United States in 2012 will be done robotically. With over half a million hysterectomies done each year in the US alone, gynecologic surgery is one of the main driving forces behind the growth of robotic surgery. Other applications in gynecology include myomectomy, oophorectomy and ovarian cystectomy, resection of endometriosis andlymphadenectomy. Advantages of the surgical robot are clearly seen in myomectomy. The wrist motion allows for better, more precise suturing than conventional “straight stick” laparoscopy. The strength of the arms allow for better pulling of the suture and the third arm for holding the suture on tension. Other advantage of the robot is scaling of the movements when big movement on the outside translates to very fine movement on the inside. This enables much more precise surgery and may be important in the procedures like tubal anastomosis and implantation of the ureter. Three-dimensional vision provides excellent depth of field perception. It is important for surgeons who are switching from open surgeries and preliminary evidence shows that it may allow for better identification of lesions like endometriosis. Another big advantage of robotics is that the surgeon sits comfortably with his/her arms and head supported. This results in much less fatigue and therefore increases precision and potentially may decrease the number of medical errors. The eyes of the surgeon are directed at where the hands should be, which is more natural, allows for a more natural body position and mimics open surgery. Robot also enables better teaching, especially when two consoles are used. The surgeon and the student may be either sharing the instruments with two consoles or switching between one another. In a situation where the student operates, the surgeon can use the telestation to teach. Robotic simulator attached to one of the consoles allows students to practice after hours. In summary, surgical robot is a great tool, especially in gynecology but also in urology, cardiac surgery, general surgery and laryngology. The device will evolve and most likely with time will eliminate laparoscop

Changes in the parameters of the anterior segment of the eye in pregnant women — literature review

The physiology of pregnancy is a curious issue for specialists from different branches of medicine and science. In this systematic review, the attention was focused on changes in eyes during pregnancy and confinement. To summarise and systematize actual knowledge in eyes’ changes during pregnancy, publications from years 2011–2017 were analysed. Stud­ies about parameters of corneal endothelial cells, corneal biomechanical parameters, keratometric variables, intraocular pressure and biometry of the anterior chamber were compared. The conducted studies demonstrated the unambiguous character of changes only in case of intraocular pressure, which decreased during the II and III trimesters of pregnancy. Inconsistent study methods and low number of examined patients did not enable to draw explicit conclusions in context of other parameters of the anterior segment of the eye in pregnant women. It is indicated to perform further studies on a representative and homogeneous group of female patients

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