How the cesarean delivery rate decreased at the Department of Obstetrics and Gynecology, University of Debrecen during the COVID-19 pandemic / Hogyan csökkent a császármetszések aránya a debreceni Szülészeti Klinikán a koronavírus-pandémia alatt?

Összefoglaló. Bevezetés: Az új koronavírus (SARS-CoV-2) okozta pandémia számos változást eredményezett életünk minden területén, így a debreceni Szülészeti és Nogyógyászati Klinikán is. Célkituzések: A koronavírus-járvány többek között a terminus körüli elektív szülésindukciók gyakorlatának megváltoztatását igényelte. A bevezetett új szakmai eljárásrendeknek, járványügyi intézkedéseknek, a megyei kórházi funkciót ellátó debreceni Kenézy Kórház Szülészeti Osztálya és a Szülészeti Klinika összevonásának, illetve a megváltozott jogi környezetnek a szülészeti ellátásra kifejtett együttes hatásait elemezzük. Módszerek: Helyi protokollokat és részletes eljárásrendeket készítettünk és vezettünk be. 1. Szülésindukció. 2. Szülésindukció cervixérlelést igénylo esetekben. 3. A szülés módjának megválasztása elozményi császármetszés után. 4. A császármetszés utáni hüvelyi szülést támogató, terminus körüli gondozási protokoll. A protokollok bevezetését követo elso 9 hónap szülészeti mutatóit (szülésszám, császármetszések aránya, perinatalis kimenetel, szülésindukciók aránya és sikeressége) vizsgáltuk és hasonlítottuk össze a megelozo idoszak debreceni adataival, illetve az országos szülészeti mutatókkal. Eredmények: Klinikánkon a császármetszés aránya 2020-ban 33,5%-ra csökkent, a protokollok bevezetése óta pedig 30,7%, miközben a 2020. évi magyarországi arány 40,3%. Az összes szülés 20%-a volt 2020-ban szülésindukció, melyek közül 74% végzodött hüvelyi szüléssel, míg ugyanez 2019-ben 11% indukcióból 47%-nak adódott. A havi szülésszám 2020. január és 2021. január között folyamatosan emelkedett (250-rol 450-re), a havi császármetszési arány pedig 41%-ról 25%-ra csökkent. Mindezen változások mellett 2019-rol 2020-ra csökkent mind a perinatalis mortalitás (6,3‰-rol 4,2‰-re), mind a szülés után a Neonatalis Intenzív Centrumba történo felvételek aránya (14,8%-ról 13,5%-ra). Következtetések: A bemutatott tényezok együttes hatásaként - elsodlegesen a megfelelo és következetesen betartott protokolloknak köszönhetoen - a szülésindukciók aránya és sikeressége jelentosen növekedett, a császármetszések aránya szignifikánsan csökkent, javuló perinatalis morbiditási és mortalitási mutatók mellett. Orv Hetil. 2021; 162(21): 811-823. INTRODUCTION: The pandemic caused by the new coronavirus (SARS-CoV-2) has catalized several changes in many fields of our lives, and also at the Department of Obstetrics and Gynecology of the University of Debrecen, Hungary. OBJECTIVES: We wanted to analyse the compound effect of our new local protocols regarding elective labour inductions at term, the coronavirus pandemic and the resulting infection control measures, the merging of the Obstetrics and Gynecology Ward of the Kenézy County Hospital of Debrecen and the University Department of Obstetrics and Gynecology, and also the change of the legal environment. METHODS: Local protocols were introduced: 1. Labour induction. 2. Cervical ripening in labour induction. 3. Choosing the route of delivery after cesarean. 4. Management of pregnancy around term in the case of planned trial of labour after cesarean. We compared the obstetrical data (number of deliveries, cesarean section rate, perinatal outcome and the rate and success rate of labour inductions) before and after the implementation of the protocols. The results were also compared to the Hungarian national database. RESULTS: The annual cesarean rate at our department dropped to 33.5% in 2020. In the first 9-month period, after the introduction of the new reforms, the cesarean rate decreased to 30.7%, whereas the Hungarian national rate was 40.3% in 2020. At our department, 20% of all the deliveries were induced and 74% of them led to vaginal deliveries in 2020, while in 2019 only 11% of deliveries were labour inductions, and 47% of these cases were vaginal deliveries. The monthly number of deliveries was rising constantly between January 2020 (250 deliveries) and January 2021 (450 deliveries), and the monthly cesarean rate decreased from 41% to 25%. Comparing the data of 2019 and 2020, the annual perinatal mortality rate dropped from 6.3‰ in 2019 to 4.2‰ in 2020. Neonatal morbidity, as measured by admissions to the neonatal intensive care unit, also decreased (14.8% in 2019 and 13.5% in 2020). CONCLUSIONS: As a compound result of the described factors, but mainly due to the new protocols, both the rate and the success rate of labour inductions increased significantly, while the cesarean rate decreased with improving perinatal mortality and morbidity. Orv Hetil. 2021; 162(21): 811-823.

Blood rheology during normal pregnancy.

INTRODUCTION: Recent studies have shown increased RBC aggregation and no difference in plasma viscosity in the presence of markedly lower hematocrit in women at term compared to non-pregnant women. Little is known about the outcome of blood rheological parameters and red blood cell (RBC) deformability particularly in the course of normal pregnancy. METHODS: During a 36 months interval 1.913 blood samples were randomly collected from a total of 945 pregnant women in the course of their pregnancy (n = 1.259) and during puerperium (upto 1 week; n = 654). Next to the blood count, hemorheological parameters including red blood cell (RBC) -aggregation (stasis E0; low shear E1), -deformability (low, moderate and high shear conditions) and plasma viscosity (pv) were assessed. Plasma viscosity (pv) was examined using KSPV 1 Fresenius, RBC aggregation (stasis: E0 and low shear: E1) using MA1-Aggregometer; Myrenne and RBC deformability (def) was determined by Rheodyn SSD Diffractometer, Myrenne, Roetgen, Germany were tested. In some of these women laboratory results prior to pregnancy (n = 145) were available which were compared with those during pregnancy. RESULTS: Mean maternal pv remained unchanged within each trimester and compared to the values before pregnancy and during early puerperium (Range of means: 1.18-1.20 mPa S). In contrast, RBC agg (E0 and E1) was markedly higher in the 2nd (21.8 ± 7.0 and 28.9 ± 9.4; p < 0.001) and 3rd trimester (18.74 ± 8.4 and 28.2 ± 9.4; p < 0.01) compared to the values before pregnancy (16.4 ± 6.4 and 20 ± 7.5) and during 1st trimester (17.49 ± 6.5 and 22.4 ± 7.4). There was a stat. significant temporary reduction in RBC def. under all shear rate conditions during 2nd trimester compared to the values before pregnancy which remained significantly lower during 3rd trimester only under high shear rates.An increase RBC agg was stat. significantly inversely correlated with reduced RBC def being most pronounced under low shear rate conditions. While RBC rigidity was stat. significantly correlated with higher hematocrit values there was only a weak correlation between RBC agg and haematocrit (E0: r = -0.084; p = 0.03; E1: r = -0.06; p = 0.1). Pv was not correlated with haematocrit or RBC def but stat. significantly correlated with RBC agg. CONCLUSIONS: Blood rheological changes manifest during 1st trimester, and fairly remain unchanged during 2nd trimester until term. Physiologic hemodilution and increasing hypercoagulability is accompanied by high RBC -aggregation and - rigidity during 2nd trimester while plasma viscosity remains nearly unaffected throughout normal pregnancy.

Intention-to-Treat Analysis of Radical Trachelectomy for Early-Stage Cervical Cancer With Special Reference to Oncologic Failures: Single-Institutional Experience in Hungary.

OBJECTIVE: The aim of our study was to evaluate clinical and pathological data in order to draw eligibility criteria for oncologically sufficient radical trachelectomy (RT) in early-stage cervical cancer. Reviewing all cases of attempted RT performed at our unit, we focused attention on prognostic indicators of the need for additional oncologic treatment following RT. The analysis was extended by extensive literature review to include previously published cases of oncologic failures. METHODS: The authors retrospectively analyzed data of patients who underwent RT at the Department of Obstetrics and Gynecology, University of Debrecen. Electronic records and case notes of RT cases were reviewed to determine the incidence of abdominal and vaginal route, distribution of clinicopathologic data, and follow-up results of individual cases. Individual procedures were categorized as oncologically insufficient if additional oncologic treatment was necessary following RT. Theoretical eligibility criteria for RT in early-stage cervical cancer were determined retrospectively by selecting prognostic features that were associated with oncologic insufficiency from clinicopathologic indicators of the complete series. RESULTS: Twenty-four cases of RT were performed by the authors, 15 vaginal RTs with laparoscopic pelvic lymphadenectomy and 9 abdominal RTs with open pelvic lymphadenectomy. Fifteen of 24 cases proved oncologically sufficient. Three cases required immediate conversion to radical hysterectomy because of positive sentinel nodes and/or positive isthmic disc on frozen section. In further 5 cases, final pathology results indicated additional oncologic treatment, that is, radical hysterectomy (n = 2), chemoradiotherapy (n = 2), or chemotherapy (n = 1). One patient among immediately converted cases and another 3 among those who required additional oncologic treatment died of their disease later. There were no other cases of recurrences over a median follow-up of 34 months (range, 12-188 months). Factors that may predict oncologic insufficiency of RT were stage IB1 or greater, tumor size of greater than 2 cm in 1 dimension or greater than 15 mm in 3 dimensions, G3, nonsquamous/adeno histological type, stromal invasion of greater than 9 mm, and lymphovascular space involvement in the primary tumor. CONCLUSIONS: Most cases of oncologically insufficient RTs have significant risk features that can be identified preoperatively. There is a need for more clinicopathologic data on oncologic failure of RT cases in order to improve patient selection.

[Management of twin births]. / Szülésvezetés ikerszülés esetén.

INTRODUCTION: The rate of multiple births has increased all over the world in the past decade. This is mainly due to the widespread use of infertility treatments and assisted reproductive techniques. Despite of improvements in obstetric and neonatal care, twin pregnancy still mean high risk both for the mothers and their babies. The management of twin delivery remains controversial. PATIENTS AND METHOD: Authors analyzed the data of all twin pregnancies at the Department of Obstetrics and Gynecology, University of Debrecen between January 2002 and December 2003. The data of 113 twin pregnancies were analyzed. Details of gestational age, presentation, birth weight discordance, mode of delivery were reviewed. RESULTS: From the 113 analyzed twin births, 27 pregnancies have been conceived after successful assisted reproductive technique. In 18 cases more than 500 grams of body weight difference was detected between the two babies at the time of delivery. The rate of preterm birth was 69%, and cesarean section was performed in 64% of preterm births compared to 68.6% in the matured delivery group. CONCLUSIONS: On the basis of recent data a large prospective, randomized trial is mandatory to determine the optimal management of twin deliveries.

[Isolated ovarian abscess in the puerperium]. / Szülés után kialakuló izolált petefészektályog.

Isolated ovarian abscess is the infection of the ovary without tubal involvement. A number of predisposing factors have been identified. The appearance after spontaneous vaginal birth is rare. The clinical presentation is varied, the symptoms are not specific. Proper diagnosis necessitates the complete evaluation of clinical signs, laboratory tests and imaging techniques. The effective treatment is mostly operative. The authors present the detailed management of a postpartum patient with an isolated abscess of the right ovary. Antenatal identification and treatment of cervico-vaginal infection along with strict antiseptic way of care during labor and delivery may result in less prevalent and less severe postnatal maternal inflammatory complications.