Miroslava Pervulov

Comparison of two therapeutic protocols in patients with antiphospholipid antibodies and recurrent miscariages

AIM To compare the effects of two therapeutic protocols for the patients with recurrent miscarriages associated with the presence of antiphospholipid (anticardiolipin) antibodies. METHODS A prospective observational study included 20 patients with antiphospholipid antibodies in the first group who received low-molecular heparin and aspirin. The second group of 20 patients, in addition to this therapy, received immunotherapy (intravenous immunoglobulin). Aspirin was administered at the time of a positive pregnancy test, and low-molecular heparin not before the fetal heart activity registration by ultrasound. Intravenous immunoglobulin was given prior to the conception or at the beginning of the pregnancy. We compared these groups according to the pregnancy outcomes and the occurrence of complications during pregnancy, using standard statistical tests. RESULTS The rate of positive gestational outcome in the patients treated with aspirin and low-molecular heparin was 85% (17/20), and in the second group it was 90% (18/20). There was no significant difference in pregnancy outcomes between these groups (p > 0.05), except for the occurence of preeclampsia and thrombocytopenia, which were recorded only in the aspirin and low-molecular heparin group, but with no statistical significance (p > 0.05) compared to the second group, which received immunoglobulin additionally. CONCLUSION There was no significant difference (p > 0.05) in pregnancy outcomes between the two studied therapeutic protocols, but the therapy with aspirin and low-molecular heparin was cheaper and easier to apply than the therapy with immunoglobulins. The results of our study confirmed that the final pathogenic mechanisms in recurrent fetal miscarriages were inflammation and thrombosis of the uteroplacental blood vessels.

Intra-amniotic Chlamydia trachomatis infection.

Chlamydia trachomatis is one of the most prevalent genital pathogens in pregnant women. Ascending, transcervical infection may reach fetal membranes creating chorioamnionitis or amniotic fluid infection. The aim of this study was to examine amniotic fluids obtained during cesarean section for the presence of chlamydial IgM- and IgG-specific antibodies, and for the presence of C. trachomatis antigen. Five of 52 (9.6%) amniotic fluid samples were seropositive. Two of 52 (3.8%) amniotic fluid samples had C. trachomatis antigen in the epithelial cells of the amnion. In conclusion, our data indicate that there is a high rate of transmission of C. trachomatis from mother to infant and that the pathogen can be identified in the amniotic fluid.

The effects of adjuvant insulin therapy among pregnant women with IGT who failed to achieve the desired glycemia levels by diet and moderate physical activity

Objective: Evaluation of adjuvant insulin therapy effects on glycemic control, perinatal outcome and postpuerperal glucose tolerance in impaired glucose tolerance (IGT) pregnant women who failed to achieve desired glycemic control by dietary regime. Methods: A total of 280 participants were classified in two groups: Group A patients continued with dietary regime and Group B patients were treated with adjuvant insulin therapy. Glycemic control was assessed by laboratory and ultrasonograph means. Pregnancy outcomes were evaluated by prevalence of pregnancy induced hypertension (PIH), high birth weight, neonatal hypoglycemia and caesarean section rates. Postpuerperal glucose tolerance was assessed by oral glucose tolerance test (oGTT). Results: All laboratory and ultrasound indicators of glycemic control had significantly lower values in Group B. Group A women were more likely to develop the EPH (Edema, Proteinuria, Hypertension) syndrome, 20% versus 7.86% (p = 0.003). High birth weight occurred more frequently in Group A, but the difference was not significant (p = 0.197). Higher rate of caesarean delivery was in Group A than in Group B, 16.43% versus 26.43% (p = 0.041). The difference in neonatal hypoglycemia was not significant (p = 0.478). Pathological oGTT results were observed in 73 Group A patients and in 15 Group B patients. Conclusion: Lower caesarean section rates and the EPH syndrome incidence are the benefits of adjuvant insulin therapy in IGT patients.

Cerebrovascular diseases during pregnancy and puerperium.

Objective. We have studied 37 women with all forms of cerebrovascular diseases. Our aim was to study the etiology, clinical manifestations and prognosis of such conditions during pregnancy or puerperium. Methods. We analyzed the most common causes of cerebrovascular diseases during the given period. Results. The most common causes of cerebrovascular diseases during pregnancy or puerperium are hematological coagulation disorders, cardio embolism and eclampsia, whereas other causes ara rarer. Conclusions. The incidence of cerebrovascular diseases during pregnancy or puerperium is 11%. Cerebrovascular diseases are more frequent in puerperium than during pregnancy, being 1.8:1. Etiology remains undetermined in 35% of the cases.

Different medicaments in fetus maturation–corticosteroid usage

Objective. The object of work is pointing out the significance of improvement highly risk pregnancies by applying artificial fetal lungs maturation in relation to expected outcomes without adequate therapy. Methods. We analyzed fetal lung maturation by using lecithin and sphingomyelin ratio in embryo fluid received by foam test. We examined successfulness of artificial fetal lungs maturation by applying corticosteroids to the embryo in a group of patients with serious form of growth retardation (group A), then to the mother (group B) and by inducing partial mild form of asphyxia with oxytocin infusion (group C). Results. The success of the method is shown by the success of finished pregnancies. We followed the difference between expected and actual term of delivery. Conclusion. Artificial fetal lungs maturation by applying fetal corticosteroids efficiently increases the creation of lecithin and sphingomyelin and enables life of neonate even in period up to 30th week of gestation.

Spontaneous twin pregnancy in a 56-year-old primipara.

Sir, Pregnancies at the extremes of reproductive age are very rare, but seem to be increasing in frequency w3, 8x. Nevertheless, these pregnancies reach wide public attention and are of special concern to health workers. The aging-related ovarian dysfunction is a frequent reason for subfertility w11x, whereby the ovarian reserve of primordial follicles (in quatitative and qualitative terms) after 40 years of age is much reduced w9x, leading to agerelated subfertility. However, it should be noted that if the functional reserve of the ovary remains adequate and responds positively to gonadotrophic stimulation, the chances of an older woman to conceive is quite similar to that of a younger woman. At the same time, the higher incidence of chromosomal abnormality is increasing significantly with the years of age w4, 6x and the chance of a normal conception is much decreased. Spontaneous pregnancies in older mothers are occasionaly reported. This occurrence raises certain questions related to the mechanism of conception, the consequences of maternity at an advanced age, and the natural history of such pregnancies. Sometimes, an extraordinary case provides insight and clues for our understanding of the ordinary. We present a case of a 56-year-old primipara with spontaneous twin gestation complicated with pregnancy-induced hypertension. A 56-year-old primipara was hospitalized due to pregnancy-induced hypertension at 26 weeks of her twin ges-

Acceleration of fetal maturation by oxytocin-produced uterine contraction in pregnancies complicated with gestational diabetes mellitus: a preliminary report.

BACKGROUND Prevention of the permanent sequelae of fetal hyperinsulinemia, namely hypertension and obesity, in infants born to mothers with gestational diabetes mellitus (GDM) has remained unresolved. Efforts to reduce fetal macrosomia by attempting to maintain blood sugar within a certain range have certainly failed. We have tried to eliminate fetal macrosomia by accelerating fetal maturation and delivery before the 36th week. METHODS Acceleration of fetal maturation was achieved by endogenous release of thyrotropin-releasing hormone brought about by periodic fluctuations in fetal oxygenation resulting from oxytocin-produced uterine contractions. Fifteen patients with GDM at 33-35 weeks, six of whom had previously given birth to a macrosomic fetus, agreed to participate in the study. Oxytocin was given for 6 h per day to produce regular contractions. In 13 patients it was given for 5 days, and in two patients for 7 days to reach a lecithin/sphingomyelin (L/S) ratio indicative of fetal maturity. RESULTS Eleven patients delivered vaginally after induction of labor and four delivered by Cesarean section. The mean Apgar score at 5 min was 9.13, and the mean birth weight was 2917 g (range 2100-3400 g). No newborn had respiratory difficulties, although four had short episodes of tachypnea. All were cared for in the regular nursery and all were discharged home with their mothers. CONCLUSION Acceleration of fetal maturation, and delivery between 34 and 36 weeks, appears to be a promising means to reduce or even eliminate the permanent sequelae of fetal hyperinsulinemia in pregnancies complicated by GDM.