Pelvic inflammatory disease and surgical treatment over a ten years period; single institution experience

Background: In our study, we examined the frequency of surgical procedures due to the acute presentation of the pelvic inflammatory disease (PID) in regard to all gynecological procedures in a single institution. We also wanted to present patients\u27 age range and type of surgical approach as well as surgical extension. Materials and methods: This retrospective study investigated a total of 10,175 surgical procedures, out of which 103 were due to acute PID. The study included 101 patients. We obtained data from surgical procedures performed from September 2009 to September 2019. Results: In the observed ten years period, the frequency of surgical procedures due to the acute PID was 1.01%. It was found that women were mostly older than 25 (85.15%). Laparoscopy was performed in 52.43% of cases and laparotomy in 37.86% of cases. Laparotomy incisions were transverse in 26.67% of cases and vertical in 42.22% of cases. The most radical procedures were performed in 17.48% of cases in which patients underwent a subtotal or total hysterectomy with unilateral or bilateral adnexectomy. Conclusion: In conclusion, although rare, surgical procedures in PID are relevant because they are, according to our data, more common in patients older than 25, and surgical procedures tend to be more extensive

HETEROTOPIC TRIPLET PREGNANCY (TWINS IN THE UTERINE CAVITY, THIRD EMBRYO IN THE CERVIX) CONCIEVED IN SPONTANEOUS NON STIMULATED MENSTRUAL CYCLE. CASE REPORT

Sažetak. Unatoč porastu učestalosti višeplodnih i heterotopičnih trudnoća i to uglavnom zahvaljujući sve češćoj primjeni metoda potpomognute oplodnje, one su kod spontanih začeća u nestimuliranim menstruacijskim ciklusima još uvijek veoma rijetke. U ovom prikazu radi se o 37-godišnjoj bolesnici, njenoj petoj trudnoći s dva ranija poroda, s troplodnom trudnoćom gdje su blizanci implantirani intrauterino, a treći embrio se implantirao u području cerviksa. Pokušaj konzervativnog liječenja pacijentice metotreksatom pokazao se neuspješnim te je unatoč primjeni konzervativnih kirurških metoda liječenja pacijentici zbog po život opasnog krvarenja učinjena totalna abdominalna histerektomija.Despite rising incidence of multiple and heterotopic pregnancies mostly due to increased incidence of assisted conception techniques, they are still very rare after spontaneous conception in non stimulated menstrual cycle. In this report, 37 year old gravida 5 para 2, concieved triplet pregnancy with twins in the uterine cavity and third embryo implanted in the cervix. An attempt of conservative treatment with systemic Methotrexate was unsuccesful and despite the attempt of conservative surgical methods she ended with total abdominal hysterectomy for life threatening hemorrhage

HETEROTOPIC TRIPLET PREGNANCY (TWINS IN THE UTERINE CAVITY, THIRD EMBRYO IN THE CERVIX) CONCIEVED IN SPONTANEOUS NON STIMULATED MENSTRUAL CYCLE. CASE REPORT

Sažetak. Unatoč porastu učestalosti višeplodnih i heterotopičnih trudnoća i to uglavnom zahvaljujući sve češćoj primjeni metoda potpomognute oplodnje, one su kod spontanih začeća u nestimuliranim menstruacijskim ciklusima još uvijek veoma rijetke. U ovom prikazu radi se o 37-godišnjoj bolesnici, njenoj petoj trudnoći s dva ranija poroda, s troplodnom trudnoćom gdje su blizanci implantirani intrauterino, a treći embrio se implantirao u području cerviksa. Pokušaj konzervativnog liječenja pacijentice metotreksatom pokazao se neuspješnim te je unatoč primjeni konzervativnih kirurških metoda liječenja pacijentici zbog po život opasnog krvarenja učinjena totalna abdominalna histerektomija.Despite rising incidence of multiple and heterotopic pregnancies mostly due to increased incidence of assisted conception techniques, they are still very rare after spontaneous conception in non stimulated menstrual cycle. In this report, 37 year old gravida 5 para 2, concieved triplet pregnancy with twins in the uterine cavity and third embryo implanted in the cervix. An attempt of conservative treatment with systemic Methotrexate was unsuccesful and despite the attempt of conservative surgical methods she ended with total abdominal hysterectomy for life threatening hemorrhage

AORTO-LEFT VENTRICULAR TUNNEL – FETAL DIAGNOSIS AND EARLY NEONATAL TREATMENT AS A PRECONDITION FOR SUCCESFUL DISEASE OUTCOME

Prikazujemo pacijenta s aorto-lijevo ventrikulskim tunelom (ALVT, engl. aorto-left ventricular tunnel) kojemu je dijagnoza postavljena u gestacijskoj dobi (GD) od 27 tjedana. Indikaciju za pregled postavio je opstetričar zbog kardiomegalije. Ona se očitovala izrazitom dilatacijom lijeve klijetke (LVIDd 32 mm, >2SD), značajno smanjenom sposobnosti kontraktilnosti (EF 40 %) i obojenim doplerskim prikazom asimetrične insufi cijencije aortalne valvule putem kanala koji ide od sinotubularne konekcije do lijeve klijetke, između interventrikulskog septuma i subinfundibularnog trakta desne klijetke. Ventrikulska učinkovitost (engl. Myocardial Performance Index –MPI ili Tei indeks) bio je 0,62 (n.v. 0,25-0,50), kardiovaskularni profi l (engl. Cardiovascular Profi le Score – CVPS) prema Huhtai 4 (normalno 10), a-val u duktus venozus (DV) pozitivan (++) (kao siguran dokaz srčane insufi cijencije kod fetusa) i pozitivne pulsacije u umbilikalnim venama. Uz to je nađena ekstremna dilatacija tubularne aorte (18 mm – >2 SD, iznad 95. percentile). Prsten aortalne valvule u toj gestacijskoj dobi iznosi 5,8 mm (75. percentila), a širina ekstravalvularnog tunela 4-5 mm. Intrauterino se ne provodi medikamentno liječenje jer nije nađen hidrops. I postpartalno se nalazi kardiomegalija (rendgenska slika), a ehokardiografski potvrđuje dijagnoza ALVT-a. Kanal se nalazi iznad desnog koronarnog kuspisa, odnosno ispred rafe koja spaja lijevi i desni koronarni kuspis tako da se nalazi i dijagnoza bikuspidalne aortalne valvule (BAV) anteroposteriorne orijentacije. Zbog razvoja srčane insufi cijencije ordinira se inotropna i diuretska terapija. Dijagnoza je potvrđena i MSCT-om te kateterizacijom srca (angiokardiografi ja). Kardiokirurška operacija učinjena je u dobi od 16 dana postavljanjem autologne perikardijske zakrpe (engl. patch) na aortalni otvor kanala. Postpartalno se ordinira diuretik, digitalis i ACE inhibitor. Postupno dolazi do oporavka lijeve klijetke (3 mjeseca nakon operacije EF 50 %), ali perzistira patološka dilatacija tubularne aorte. Očekuje se potpuni oporavak lijeve klijetke uz potrebu daljnje opservacije bolesnika zbog bikuspidalne aortalne valvule s mogućim reperkusijama na samoj valvuli i uzlaznoj aorti. U dobi od 10 mjeseci nađena je uredna kontraktilnost lijeve klijetke (EF 65 %), blaga aortalna insufi cijencija (centralna), uz uredan protok kroz aortalnu valvulu, ali dalje postoji dilatacija uzlazne aorte (promjer 2,1 cm, >2 SD).We present a patient with aorto-left ventricular tunnel (ALVT) diagnosed in the gestational age (GA) of 27 weeks. Examination was indicated by an obstetrician due to cardiomegaly. ALVT manifested itself by an extreme dilatation of the left ventricle (LVIDd 32 mm, >2 SD), a signifi cantly decreased contractile ability (ejection fraction (EF) 40%) and color Doppler display of an asymmetric aortic valve insuffi ciency via a canal fl owing from the sinotubular junction to the left ventricle, between the interventricular septum and subinfundibular portion of the right ventricle. Myocardial performance index was 0.62 (normal 0.25-0-50), cardiovascular profi le score 4 (normal 10), a-wave in ductus venosus (DV) positive (++) (as positive evidence for fetal cardiac dysfunction) and positive umbilical venous pulsations. In addition, an extremely dilated tubular aorta was also found (18 mm – >2 SD, above 95th percentile). In that gestational age, aortic valve ring was measured 5.8 mm (75th percentile), and the width of extravalvular tunnel 4-5 mm. Since no hydrops was found, in utero treatment with medicines was not used. Cardiomegaly was found postpartum (x-ray), and the ALVT diagnosis was confi rmed by echocardiography. The canal was located above the right coronary cusp, i.e. in front of the raphe connecting the left and right coronary cusp, meaning that the diagnosis of a bicuspid aortic valve (BAV) of anterior-posterior orientation was also made. Inotropic and diuretic therapy was ordered due to cardiac insuffi ciency development. Diagnosis was also confi rmed with multi-slice computed tomography and heart catheterization (angiocardiography). Cardiac surgery was performed at the age of 16 days by placing an autologous pericardial patch on the aortic canal opening. Diuretic, digitalis and angiotensin-converting enzyme inhibitor were ordered postnatally. Left ventricle was recovering incrementally (3 months after surgery, EF 50%), but pathological dilatation of tubular aorta persisted. Complete recovery of the left ventricle is expected, with the need for further observation of the patient because of the BAV and possible effects on the valve itself and on the ascending aorta. At the age of 10 months, contractility of the left ventricle was normal (EF 65%), with mild aortic insuffi ciency (central), normal fl ow through the aortic valve, but dilatation of the ascending aorta persisted (ascending aorta width 2.1 cm, >2 SD)

ACUTE ABDOMEN TWO DAYS AFTER VAGINAL BIRTH AFTER CESAREAN SECTION

Prikazan je slučaj akutnoga abdomena u babinju sa znacima difuznoga peritonitisa i paralitičnoga ileusa nastalih dva dana nakon nezamijećenog kompletnog razdora maternice u vaginalnom porođaju poslije prethodnoga carskoga reza i manualne eksploracije materišta. Učinjena je eksploracijska laparotomija, intestinalna adhezioliza, revizija i šavi maternice, lavaža trbušne šupljine i drenaža. Nakon operacije bolesnica se potpuno oporavila uz sačuvanu fertilnost. Raspravlja se o medicinskim i forenzičkim aspektima.A case is presented of puerperal acute abdomen with diffuse peritonitis and paralytic ileus two days after unnoticed complete uterine rupture after VBAC (vaginal birth after cesarean section) and uterine cavity obstetric examination. Explorative laparotomy, intestinal adhesiolysis, uterine revision and sutures, abdominal lavage and drainage were performed. The operation was followed by successful recovery and intact fertility. Medical and forensic aspects are discussed

Spontana heterotopična, ektopična cervikalna i ektopična tubarna trudnoća - uvijek prisutna dijagnostička poteškoća: prikaz triju slučajeva

The incidence of heterotopic/ectopic pregnancy in recent times has increased partly due to the increase in assisted reproductive technologies, whereas such medical cases and cervical pregnancy in particular are extremely rare with spontaneous conception. We report on three patients referred to our department in one week: one patient each with spontaneous heterotopic pregnancy, cervical pregnancy and tubal pregnancy. All of them had conceived spontaneously and were properly diagnosed and treated, however, additional care is needed in diagnosing and managing the potentially fatal consequences of ectopic pregnancy if not recognized early and managed properly, despite its low incidence.Incidencija heterotopičnih/ektopičnih trudnoća se u posljednje vrijeme povećava između ostalog i zbog sve veće upotrebe metoda pomognute oplodnje, ali ovi slučajevi, a naročito cervikalna trudnoća, iznimno su rijetki u spontanim zanošenjima. Prikazujemo tri bolesnice koje su se javile u našu Kliniku u tjedan dana: bolesnica sa spontanom heterotopičnom trudnoćom, druga s cervikalnom i treća s tubarnom trudnoćom. Sve su spontano zanijele, pravodobno dijagnosticirane i izliječene, ali naglašavamo da je osobita pozornost potrebna u dijagnozi i liječenju potencijalno fatalnih posljedica izvanmaterničnih trudnoća ako nisu prepoznate i liječene dovoljno rano, unatoč tako iznimno rijetkoj pojavnosti

Is sonographic assessment of cervical length better than digital examination in screening for preterm delivery in a low-risk population?

BACKGROUND: This randomized controlled trial compared the diagnostic accuracy of the sonographic assessment of cervical length and clinical digital examination of the cervix in the second trimester regarding the prediction of preterm delivery in a low-risk population. ----- METHODS: In total, 282 unselected, asymptomatic women with singleton pregnancy randomly underwent sonographic cervical length measurement (study group, n=138) or clinical digital examination (control group, n=144) in the second trimester. In the study group cervical length or=95th percentile (>or=4) for our population was defined as high. The primary outcome measure was the diagnostic accuracy of both tests regarding the prediction of preterm delivery (<37 weeks). Results: Shortened cervical length was found in 6/138 (4.3%) women whereas the high Bishop score was found in 17/144 (11.8%) (p=0.038, Fisher's exact test). The incidence of preterm delivery was 5.7% (16/282). Regarding the prediction of preterm delivery, shortened cervical length and high Bishop score had sensitivity 57.1% versus 33.3% and positive predictive value 66.7% versus 17.6%. Shortened cervical length in comparison with high Bishop score had 12-fold higher positive likelihood ratio for preterm delivery in a low-risk population (37.4; 95%CI [8.2-170.7] versus 3.2; 95%CI [1.1-9.2]). ----- CONCLUSION: Sonographic assessment of cervical length has better diagnostic accuracy in the prediction of preterm delivery compared to digital examination in a low-risk population

Placental site does not change background uterine electromyographic activity in the middle trimester of pregnancy

OBJECTIVE: This study was performed in order to assess the potential influence of placental implantation site on transabdominal electromyographic (EMG) assessment of the uterine electrical activity in the middle trimester of pregnancy. - - - - - STUDY DESIGN: In this prospective study 251 unselected, nulliparous asymptomatic women with a singleton pregnancy underwent transabdominal uterine EMG. Uterine electrical activity was recorded using bipolar electrodes placed on the abdominal surface for 20min. Regarding the placental implantation site and presence of action potentials (AP) pregnant women were divided into two groups: the anterior placenta group (APG) and the posterior placenta group (PPG). Outcome measures were differences in the median frequency (MF) and median amplitude (MA) of AP between the two groups. - - - - - RESULTS: Action potentials were detected in 56 women: 33/56 in the APG versus 23/56 in the PPG. The parameters analyzed (MF, p=0.527, Fisher's exact test, and MA, p=0.255, Fisher's exact test) did not produce any statistical significant differences between the two groups. - - - - - CONCLUSION: Background uterine EMG activity measured from the abdominal surface in the middle trimester of pregnancy does not depend on the placental implantation site