[Disseminated intravascular coagulation syndrome and protein C]

Disseminated intravascular coagulation (DIC) is characterized by systemic activation of the haemostasis. In many instances the release of inflammatory cytokines and tissue factor trigger the system in septic or traumatic conditions. Initially, the increased activation of haemostasis can be compensated by natural inhibitor systems. As release of the triggers persists, inhibitors (e.g. antithrombin and protein C) will be consumed leading to intravascular clotting. In this process many coagulation factors, most notably fibrinogen and platelets are consumed too, resulting in a failure of haemostasis system and in a diffuse bleeding (decompensated DIC). Fresh frozen plasma, blood transfusion, and fibrinogen concentrate correct the bleeding, if needed, in the case of traumatic (obstetric) DIC. Arrest of the activated haemostasis by heparin and natural anticoagulants (antithrombin or/and protein C) is recommended, mainly in septic conditions with systemic inflammatory reactions. A case of stercoral sepsis usefully treated by recombinant human activated protein C is reported.

[The fetal ECG--ST analysis in the diagnosis of fetal hypoxia]

OBJECTIVE

Clinical tests of a new apparatus STAN S21 evaluating the foetal ECG--ST section in the diagnosis of foetal hypoxia.

DESIGN

Retrospective analysis.

SETTING

Gynaecological and Obstetric Clinic, First Medical Faculty Charles University and General Faculty Hospital, Prague.

METHOD

Within the framework of clinical tests 27 analyses were made on a apparatus STAN S21 manufactured by Swedish firm Neoventa. Contrary to hitherto implemented and published studies, in all monitored deliveries the CTG curve was evaluated as well as FpO2 and STAN. After each delivery in the neonate the Apgar score and acid-base equilibrium from the umbilical artery was evaluated. ST analysis was included mainly in case of abnormal CTG records, risk and pathological deliveries. Evaluation was divided into two groups: in one delivery was terminated by the vaginal route, in the second one by Caesarean section. For evaluation of the CTG curve the FIGO terminology was selected (intermediary-suspect) and (abnormal-pathological). For evaluation of the FpO2 pathology 30% saturation for 10 minutes was used. In STAN analysis important phenomena were evaluated by computer (increase of T wave, increase of T/QRS complex and biphasic character of ST).

RESULTS

In reduced values of the Apgar score (during the 5th minute < 8 points) and the acid-base balance from umbilical artery (pH < 7.2, BE > -8) pathological CTG records and FpO2 were present in 25%. STAN had in these instances pathological records in 50%).

CONCLUSION

ST analysis is another very effective link in the diagnosis of interpartial foetal hypoxia. Initial experience indicates, that STAN will have probably a higher diagnostic specificity than CTG and FpO2.

[Prediction of premature labor--multifactorial analysis of a prospective clinical study]

OBJECTIVE

To evaluate, which of selected anamnestic, laboratory and ultrasonographic (USG) parameters could contribute to the prediction of prematurity.

DESIGN

Prospective, observational, clinical study.

SETTING

Department of Obstetrics and Gynecology, 1st Faculty of Medicine and the General Faculty Hospital, Charles University, Prague.

METHODS

349 women with the singleton pregnancy were followed from the half of the 2nd trimester until the end of gestation. At each woman the anamnestic (age, parity, pregravid BMI, weight gain until 20th week, significant risk from patient's history, cigarette smoking, risk pregnancy symptoms until 20th week), laboratory (maternal serum concentration of AFP, hCG, and uE3/triple test/at 16th week, the blood count and ferritin concentration at 18th-20th week, bacteriological cultivation of the smear from the cervix at 34th-36th week), and USG (transvaginal cervicometry and doppler flowmetry of the uterine arteries at 18th-20th week) data were established. With the aid of one-dimensional and multi-dimensional analysis the dependence of completed gestational age and preterm delivery (before completed 37th week) on above mentioned parameters was tested.

RESULTS

314 women completed the study. We proved a significant dependence of prematurity on the following markers: risk pregnancy symptoms until 20th week (RR 2.94), abnormal triple test (RR 4.63), cultivation of pathogens from the cervix (RR 5.49), USG established cervical length (P < 0.0001), abnormal result of cervicometry (RR 19.02), both doppler parameters (RI of uterine arteries: P < 0.0001; presence of early diastolic notch: RR 2.84). The results of multi-dimensional analysis confirmed superiority of USG cervicometry in prediction of both measured outcomes.

CONCLUSION

The predictive value of some of selected anamnestic, laboratory, and USG markers of premature delivery was proved at random population of women with singleton pregnancy. The abnormal result of transvaginal USG cervicometry was the most significant predictor of prematurity. We recommend a routine performing of cervicometry (as a part of USG screening at 18th-20th week) for early selection of women with significantly increased risk of prematurity.

[Massive pulmonary embolism after delivery by cesarean section]

OBJECTIVE

To give an overview of the preventive and therapeutic measures in thromboembolic disease in association with pregnancy and delivery.

SUBJECT

Case report.

SETTING

Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General Faculty Hospital, Prague.

SUBJECT AND METHOD

The surgical treatment of massive pulmonary embolism in a patient after delivery by caesarean section.

CONCLUSION

Surgical embolectomy still has its place in the treatment of pulmonary embolism in the early phase of critical cases, when thrombolysis is contraindicated, and mechanical disintegration with the catheter is unsuccessful. In such cases it is the only one possibility of saving the patient. However, prevention of thromboembolic disease remains of primary importance.

[Perinatal outcome of twin pregnancies after fertilization in vitro and after spontaneous conception]

OBJECTIVE

To compare the obstetric outcome of twin pregnancies after IVF with spontaneously conceived twins and thus determine whether IVF twins require greater care.

TYPE OF STUDY

A retrospective study.

SETTING

The Department of Obstetrics and Gynaecology, 1st Faculty of Medicine of Charles University, Prague.

METHODS

Statistical evaluation of obstetric outcome between the group of 46 twin pregnancies after IVF and 85 spontaneously conceived twins. We evaluated the following parameters: signs of abortion and premature delivery, bleeding in pregnancy, premature rupture of membranes, performed cerclage, incidence of praeclampsia, gestational diabetes mellitus and hepatopathy of the mother. Pathological ultrasound findings were also evaluated--disturbances in foetal growth and the amount of amniotic fluid. In these parameters we also evaluated the time of the first signs of their development. Further, we evaluated the type of delivery, the gestational age at delivery, birth weight, birth weight discordance and perinatal mortality.

RESULTS

We found statistically significant differences in the method of delivery--more cesarean sections in the IVF group (71.7%) than in spontaneous ones (44.7%). Another difference was the gestational age at which cerclage were performed--earlier in the IVF group (average 22.8 weeks) than in spontaneous ones (average 25.7 weeks). In the other evaluated parameters we did not find any statistically significant differences between the two groups.

CONCLUSION

In our retrospective analysis of twin pregnancies, deliveries and neonatal outcome, except for the method of delivery and time of performing cerclage, we did not find any important significant differences between the IVF and spontaneously conceived twins. However, it is necessary to remember the generally worse obstetric outcome of twin compared to singleton pregnancies.

[The spectrum of lipids in the intrauterine growth retarded fetus and in the parents]

OBJECTIVE

The aim of this study was to determine the relationship between the parameters of individual serum lipids and the degree of intrauterine growth retardation (IUGR) of the fetus. The lipid levels were compared in fetuses with IUGR and in eutrophic fetuses and it was determined in which studied variable IUGR newborns differ from healthy newborns.

METHODS

The group under study consisted of 53 pregnant women in whom IUGR of the fetus was diagnosed by ultrasound during pregnancy. The control group consisted of 26 women who gave birth to eutrophic newborns. The cases in the control group were chosen by the method of matched control so that the results could be statistically evaluated in both groups at the same gestational age and at the same maternal age. In both groups blood samples from the umbilical cord were taken after delivery and the whole spectrum of lipid levels were evaluated (cholesterol-CH, triglycerides-TGA, high-density lipoprotein--HDL, low-density lipoprotein--LDL, Lp(a) lipoprotein, and apolipoproteins-ApoB, ApoAI, ApoE). The same parameters were evaluated in maternal and paternal blood samples. In several cases, intrauterine lipid levels of the fetus were determined by cordocentesis. The incidence of hyperlipoproteinemia in the families of both groups was surveyed.

SETTING

Department of Obstetrics and Gynaecology, 1st medical Faculty, Charles University, Prague.

RESULTS

There was a significant incidence of hyperlipoproteinemia in the families of the mothers in the group studied (chi-square test: p < 0.001). In the mothers of the groups studied, there were statistically significant higher levels of HDL, LDL, and Lp(a) in comparison to the mothers in the control group. A significant dependence was determined between the levels of ApoAI and Lp(a) of the mothers and newborns. In the regression analysis of the dependence of lipid levels on the birth weight of the newborns, a statistical correlation was determined for the values of ApoB and Lp(a).

CONCLUSION

The more increased the intrauterine growth retardation of the fetus and the lower its birth weight in relation to its gestational age, the higher its lipid levels, specifically apolipoproteins. Apolipoproteins are under genetic control and present a genetic risk for changes in the metabolism of cholesterol, hemocoagulation, and cardiovascular disease in adulthood.

[Comprehensive treatment of ileofemoral thrombosis at the end of pregnancy with cesarean section in combination with thrombectomy]

Acute deep ileofemoral thrombosis was treated at the end of pregnancy in four pregnant women. A multidisciplinary approach was selected. During a single anaesthesia the team of obstetricians and neonatologists made a Caesarean section followed by thrombectomy with a Fogarty catheter. This operation was performed by a team of specialists in cardiovascular surgery. Two women developed rethrombosis: one woman on the following day, the second one two weeks after surgery. In both instances repeated thrombectomy was performed. In one woman the cause of ileofemoral thrombosis was malignant disease of the uterine cervix II and this woman is, after oncological treatment, in a serious condition due to the basis disease. The remaining three women were repeatedly subjected to phlebographic examinations and complete patency of the deep vascular system was found. These women are free from subjective and objective complaints and can look after their children. Pregnant women where a serious ileofemoral thrombosis was diagnosed had high fibrinogen and thrombocyte levels. In two women an AT III deficiency was found. There was also a high cholesterol level and positive antiphospholipid antibodies. Thrombectomy has according to the authors' experience very good results when the operation is implemented within 72 hours after initial symptoms. This procedure reduces the risk of chronic venous insufficiency.

[Micronized progesterone in the treatment of imminent necrosis of a myoma during pregnancy. Ultrasound changes during treatment]

In two pregnant primigravidae with signs of imminent necrosis of a myoma treatment with micronized progesterone, preparation Utrogestan, was successful. After oral and vaginal treatment with a dose of 300-600 mg/day the symptoms receded within several days. Complete regression of symptoms was recorded within one to two weeks. Both women terminated their pregnancy during the 37th-38th week and were delivered of healthy infants. One women gave birth to the infant by Caesarean section, the other one per forcipem Shutte. During surgery on the myoma no signs of degeneration were found and it was left in situ. Progesterone treatment prevented in both women surgery on account of an acute abdomen. Treatment was monitored by ultrasonographic assessment of the flow in afferent vessels of the myoma. This measurement revealed marked changes, i.e. an increased flow. At the onset of treatment there was a small difference between the indices of pulsatility (PI) and resistance (RI). This difference increased gradually, and also the difference between systole and diastole in the investigated vessels increased. This led to an increased flow and blood supply of the myoma. Thus evidence can be provided that large doses of natural progesterone have a favourable effect on the blood vessels and increase the blood flow in the vascular wall at the site of the myoma.

Relation between concentration of lead, zinc and lysozyme in placentas of women with intrauterine foetal growth retardation

Intrauterine foetal growth retardation (IUGR) implies increased risk of morbidity and mortality of the newborn. Aetiology of intrauterine retardation is probably multifactorial and may include maternal infection, malnutrition, placental dysfunction, hypertension, toxaemia, smoking, professional and environmental exposure. The work concentrates on the lead, zinc and lysozyme levels in blood and placental tissues of 50 females in the IUGR group and 43 females from a control group. Statistically significant differences in zinc and lead levels between the compared group were found. The IUGR group had lower zinc and higher lead levels. A significant negative correlation of zinc and lead levels was observed. We found a statistically significant relationship between lead levels in placental tissues and the age of the pregnant women. Higher age is associated with higher lead levels in placental tissue, whereas zinc levels decrease. In placental tissues of pregnant females of the IUGR group higher lysozyme levels were found. On the basis of the discussed results the authors recommend zinc supplementation during the pregnancy.

[The HELLP syndrome]

The HELLP syndrome is a serious complication of pregnancy, found most frequently in conjunction with severe preeclampsia. The incidence of this disease in preeclampsia is between 2 and 12%. The diagnosis is based on typical laboratory findings, i.e. haemolysis--H, elevated liver enzymes--EL and a low-platelet count--LP. Haemolysis is defined as microscopic finding of an abnormal peripheral blood smear, elevated total bilirubin above 1.2 mg/dl and elevated lactate dehydrogenase above 40 mukat/l. Transaminases (AST above 4.2 mukat/l) are also elevated. For HELLP a low platelet count is typical (number of thrombocytes less than 100,000 mm3). The symptoms include above all pain in the epigastrium, in the right subcostal area, nausea and vomiting. Non-specific symptoms resembling viroses are lassitude, general weakness, headache and fatigue. A correct differential diagnosis and early assessment of the diagnosis are decisive for starting treatment which can prevent the development of serious complications such as disseminated intravascular coagulopathies and hepatorenal failure. Treatment of the HELLP syndrome is symptomatic with the objective to stabilize the general condition of the mother, improved haemodynamic conditions and the impaired haemocoagulation. A very important therapeutic step is early termination of pregnancy which depends on ther mother's condition and the condition of the foetus with regard to gestational age.

The invasive prenatal diagnosis in perinatal centre

Three main methods of prenatal diagnosis (Amniocentesis AMC, Chorionic villi sampling CVS and Cordocentesis FBS) have been used in Perinatal Centre of Central Bohemia. The chromosomal abnormalities in a group of 3,098 patients have been detected in 1.4% of fetuses. The inherited disorders were diagnosed using DNA analysis and biochemical examination of amniotic fluid. X-linked diseases in a group of 68 patients in 30.8% of fetuses have been diagnosed and inborn error of metabolism in a group of 29 indicated patients in 17.2% of fetuses were diagnosed. The incidence of fetal losses before 28th week of gestation was 0.4%.

Prenatal determination of fetal RhD (rhesus positive) type by an amplification of DNA

Examination of RhD genotype (Rhesus D gene) from amniotic cells (or chorionic villi cells) by PCR amplification of DNA can be done at early stage of pregnancy. Due to some missing exons in the Rh partial D variant (e.g. DVI), it is necessary to use different PCR systems to get relevant results. The localization of primers in our three PCR systems is on the different exons (10, 7, and 4 + 5). The advantage of PCR technique is prenatal detection of RhD of fetus from nonerythrocytes suspension (e.g. from an amnion fluid cell sediment) in comparison to a "standard" haemagglutination serological technique which uses blood erythrocytes only. The possibility of this technique to distinguished the heterozygous (D/d) or homozygous (D/D) fathers can help the clinicians in decisions about the management of further prevention of the hemolytic disease of newborn.

Biochemical screening of congenital developmental abnormalities using determination of fetoplacental antigens

In a prospective study of screening of maternal serum levels of alpha-1-fetoprotein (MS AFP) and trofoblast-specific beta-1-glycoprotein (MS SP1) were examined in samples from pregnant women between the 16th and 18th week of pregnancy. We detected 8 fetuses with chromosomal aberation, 8 fetuses with neural tube defects and 10 fetuses with inborn cardial defects. Our study confirms higher MS SP1 levels in women with fetuses with chromosomal aberation, while MS AFP's tendency is to decrease. When combining MS SP1 + MS AFP + age of mother (over 35), 75% of fetuses with chromosomal aberation were detected. In women with neural tube defect 75% fetuses were detected by MS AFP + MS SP1 combination.

[Relation of metal and lysozyme levels in the placentas of women with intrauterine fetal growth retardation]

In a group of women who gave birth to a foetus with marked growth retardation and 27 women who were delivered of eutrophic neonates the lead, cadmium, zinc and lysozyme levels in placental tissue were assessed. The investigation revealed the following results: the lead level was in the investigated group significantly higher than in the control group (15.24 ng/g vs. 11.31 ng/g). Conversely the zinc levels were significantly higher in the control group (20.52 micrograms/g vs. 14.3 micrograms/g of placental tissue). The lead, cadmium and lysozyme values rise with the womens' age in the examined placentae, while the zinc levels decline. With the elevated zinc level the lead and cadmium content in the placentae of the exposed group declines. The lysozyme values increase along with the rise of all investigated elements with the exception of zinc, where the dynamics are reversed. The findings justify the recommendation of zinc supplementation during pregnancy.

[Anti-phosphatidylserine antibodies in women with reproductive disorders]

Antiphosphatidylserine antibodies (APSA) belong to the heterogeneous population of antiphospholipid antibodies (APA) which are oriented above all against negatively charged phospholipids. The presence of APA in women is closely associated with repeated miscarriages and other complications during pregnancy. The most frequently detected specific antibodies in these patients are autoantibodies against cardiolipin and phosphatidylserine (PS). In a group of 84 pregnant women where within the framework of biochemical prenatal screening of inborn developmental defects serum levels of alpha-1-fetoprotein, choriogonadotropin and trophoblast specific beta-1-glycoprotein were examined as well as in 22 women treated for primary sterility and 22 blood donors the authors assessed, using the ELISA method, antiphosphatidylserine and cardiolipin antibodies (ACA). They found an increased prevalence of APSA in all examined groups as compared with the control group of blood donors. In pregnant women the prevalence of APSA and ACA did not differ and at least one type of antibodies was detected in 20.1%. In pregnant women with positive APSA in the case-records spontaneous abortions were recorded, or imminent abortions during the present gestation or treatment on account of sterility, and in some instances also changes of foetoplacental antigen serum levels were found. It is therefore likely that the presence of APA in women may be one of the factors participating in reproductive disorders and that assessment of APSA together with APA may extend the spectrum of immunological examinations, in particular in sterile and infertile women.

[Results and complications of intrauterine transfusion in fetuses with and without hydrops]

The group comprises 50 intrauterine transfusions in 15 patients with a severe form of foetal erythroblastosis. The authors describe the results and complications in hydropic and non-hydropic foetuses, diagnosed by ultrasound before transfusion treatment was started. In the group of non-hydropic foetuses the success rate of transfusion treatment was 90.1% and 10 neonates were born with a mean weight of 2030 g. The mean gestation period was 34 weeks. From four hydropic foetuses it proved possible to save only one, the success rate in this group was only 25%. The mean weight of hydropic foetuses was 1650 g and the gestation period at delivery 29 weeks. The rate of Caesarean sections in both groups was as high as 80%. Serious complications included thrombosis of the umbilicus, thromboembolism of the a. axillaris in a hydropic neonate and acute hypoxia of the foetus after transfusion. Four of six serious complications were recorded in hydropic foetuses.

[Is chorionic biopsy a dangerous and outdated method?]

The authors evaluated the risk of chorion biopsy used within the framework of prenatal diagnosis of the foetus. The incidence of abortions following transabdominal CVS (0.6%) did not differ from abortions after amniocentesis in the second trimester (0.5%). In a group of 1002 diagnostic biopsies of the chorion the authors did not record in the born infants reduction deformities of the extremities. Chorion biopsies were performed in 98% between the 10th and 12th week of gestation. The incidence of mosaicism--1.59%--was not significantly higher than reported in the literature. The authors recommend: to increase the size of the sample of chorion tissue by the use of a manual aspirator, the use of a 30 ml plastic syringe or the double needle method. They consider CVS a suitable method which serves the diagnosis of IUGR and the prenatal diagnosis of the foetus before the 20th week of gestation when cordocentesis involves risk.

Prenatal biochemical diagnostics of inborn developmental defects

Screening of pathological pregnancies with the use of biochemical markers determined in maternal serum is now widely accepted as a useful procedure. In our experience, the main contribution is a finding of abnormal values of one or more of the markers, which will advise gynecologist upon a possibility of a risk pregnancy.

[SP1 serum levels in pregnancy with Rh isoimmunization]

The authors examined in 37 pregnant women hospitalized on account of Rh incompatibility during the second and third trimester 71 serum specimens for levels of trophoblast specific beta 1-glycoprotein (SP1), using the method of simple radial immunodiffusion. In the group of 16 women with Rh incompatibility whose pregnancy terminated by delivery of a normal neonate, in 22% the SP1 levels were higher than 1.5 x the median value for the given gestation week (MoM). In 17 pregnancies where the foetus suffered from haemolytic disease the SP1 levels were higher than 1.5 MoM in 45% of the examined foetuses. Markedly elevated SP1 levels of 2.3 and 2.4 MoM were recorded in two pregnancies with hydrops of the foetus.