Antenatal care in developing countries. What should be done?

Development of antenatal care from the beginning of the 20th century and its relation to perinatal mortality in developed countries is presented. The role of socioeconomic factors, new diagnostic and therapeutic procedures, extended indications for cesarean section and of neonatal intensive care is also stressed. In the West- and Middle-European countries by the introduction of antenatal care the perinatal mortality (PNM) rate decreased from about 60.0@1000 in the years 1920-1930 to about 40.0@1000 in 1950s. Further decrease to about 25.0@1000 in the 1970s was conditioned by an increase of number of antenatal visits and by extended indications for cesarean section. New technologies (amnioscopy, pH.metry, cardiotocography and ultrasound examinations) decreased the PNM rate to about 13.0@1000 in the year 1980. Regional organization with neonatal intensive care units decreased PNM rate to low values of 5.0-9.0@1000. The echo of the number of antenatal visits to PNM rate is illustrated on 36,855 deliveries at the University Clinic in Zagreb. In developing countries maternal and perinatal mortality is very high. The reason for that is a bad socioeconomic background and a lack of organized antenatal and perinatal health care system. The policy to decrease maternal and perinatal mortality is presented: the improvement of antenatal booking and of the number of prenatal visits of pregnant women; their childbearing under professional assistance. The organizing of maternity health care should be different from country to country, from region to region, respectively.

Nonspecific aerobic vaginitis and pregnancy.

During the period 1996-1998, cervical swabs of 50 pregnant women with subacute amniotic infection syndrome (AIS) and the semen of their consorts were bacteriologically analyzed. In the control group were 50 healthy pregnant women and their consorts too. Pathogenic bacteria (the most common were Escherichia coli, Staphylococcus haemolyticus, Chlamydia trachomatis and Ureaplasma urealyticum) were isolated from the cervical swab of 50 pregnant patients with AIS in 86.0% of them, while in the control group of healthy pregnant women in 28.0%. Pathogenic bacteria were present in 70.0% of semen of consorts pregnant women with AIS and only in 30.0% of semen of the control group. The congruity of pathogenic bacteria in the cervical swab and semen in the investigated group was 69.2%, while only 35.7% in the control group. Following erythromycin, cefuroxime and local tetracyclin treatment, the negativization of the cervical swab resulted in 30 pregnant patients with AIS, while the colonization persisted in 20 of them. The outcome of pregnancy was significantly better in cases with negativization of the cervical swab: perinatal loss was 6.7%, while in cases with persistent infection it was 55.0%. The authors presume the amniotic infection syndrome should be ascending manifestation of nonspecific vaginitis, which is maintained by the consort's urogenital infection. AIS should be classified as a 'sexually-transmitted disease'.

[Continuing medical education in Croatia and the European Union]. / Trajna lijecnicka izobrazba u Hrvatskoj i Europskoj uniji.

The Continuing Medical Education (CME), with attention to other forms of Continuing Professional Development (CPD) in Croatia and the today endeavors in the European Union, are presented. In European Union the formal CME is in its starting. The "European Accreditation Council for Continuing Medical Education" (EACCME) of the UEMS is established, which has formulated the principles of continuing education, the credit hours and their realizing, that would enable the mutual recognition of education in all European countries. In Croatia the starting of CME was at beginning of the 20th century, when the professional societies of Croatian Medical Association were founded. CPD was almost exclusively connected to activities of "Andrija Stampar" School of Public Health, to the School of Medicine in Zagreb and partly in Rijeka, which established a great number of postgraduate studies. The CME i.e. the courses of education were tightly connected to activities of the Croatian Medical Association, of its professional societies and its Academy of Medical Sciences, but also to activities of School of Medicine in Zagreb and Rijeka, and recently in Split and Osijek. Since 1995 the third partner, the Croatian Medical Chamber joined too. The number of CME meetings during 1998 is presented. The approximate calculation for needed annual courses of CME for all medical specialties in Croatia is presented. The formation of the National Authority for CME is suggested, in which all the interested institutions should be represented.

[Committee for Human Rights and Medical Ethics of the Croatian Medical Association]. / Komisija za ljudska prava i medicinsku etiku Hrvatskoga lijecnickog zbora.

The historical development of ethical standards and institutions of Croatian Medical Association is presented. The first standards were "Medical order and Community" in 1895 and the ethical codex under the name "Main principles of Medical dignity" in 1901 resp. 1921. According to the new Association's Statute in 1990 the first "Committee on Human Rights and Medical Ethics" was founded. Since 1995 the Committee operates as a common "Committee on Medical Ethics and Deontology" of Croatian Medical Association and of Croatian Medical Chamber. In short the activities of committees in both periods, 1991-1995 and 1995-1999 are presented, including the establishing of a new "Codex of Medical Ethics". Since 1999 the Croatian Medical Chamber divorced the cooperation with Croatian Medical Association and founded his own Committee. The Croatian Medical Association is now without ethical committee. The establishment of a new, common Committee of the Medical Association, Medical Chamber and Universities is suggested.

[History of gynecology and perinatology in Croatia. Clinics and hospitals in Zagreb. Primary health care. Specialty societies of the Croatian Medical Association]. / Povijest ginekologije i perinatologije u Hrvatskoj. Klinike i bolnice izvan Zagreba. Primarna zastita. Strucna drustva Hrvatskoga lijecnickog zbora.

The formation and development of University clinics in Rijeka, Split and Osijek, and thereafter the formation and development of maternity departments in all Croatian hospitals are presented. Shortly the formation of out-patients clinics for women and maternity health-care is described, then the formation and development of Croatian Society of Gynecology and Obstetrics and of Croatian Society of Perinatal Medicine, as scientific societies (formerly "Sections") of Croatian Medical Association.

[History of gynecology and perinatology in Croatia. Midwifery. Clinics and hospitals in Zagreb]. / Povijest ginekologije i perinatologije u Hrvatskoj. Primaljstvo. Klinike i bolnice u Zagrebu.

The development of obstetrics in Croatia and the formation of unique discipline of obstetrics and gynecology in Croatia in first ten years of 20th century are presented. The midwifery is mentioned in Croatia for the first time in Dubrovnik in 14th century. The "protomedicus" from Varazdin Johan Baptist Lalangue in 1777 has published the booklet "Brevis institutio de re obstetritia". First public school of midwifery was founded in Zadar on 1820 and the second one in Zagreb in 1877. In Zadar, Ante Kuzmanic, "magister obstetritiae et chirurgiae" published a short textbook "Sixty lessons from midwifery for midwifes", thereafter in 1908 Nikola Lalich "Book for midwifes". In Zagreb, Antun Lobmayer published in 1877 "The midwifery". Gynecology was developing in the second half of 19th century as a part of surgery. On break-time from 19th to 20th century rose the unique medical profession obstetrics and gynecology. In Croatia the unique discipline established Dr Franjo Durst, since he was in 1905 installed for the first head of Royal Country Maternity Hospital in Ilica street and thereafter in 1921 for the first head and university professor of Royal University Clinic for Gynecology and Obstetrics in Petrova street. The evolution of gynecology and obstetrics, respective of perinatology, during last 30 years, in the Zagreb in departments of clinical hospitals "Clinical Hospital Center", "Sestre Milosrdnice", "Merkur" and "Sv. Duh" is presented.

[Fetal growth in pregnant women with chronic hypertension]. / Rast fetusa u trudnica s kronicnom hipertenzijom.

This study represents a retrospective analysis of pregnancies with chronic arterial hypertension and their outcomes. The aim was to evaluate the influence of arterial hypertension on 101 essential and 109 cases of secondary hypertension in comparison to the control group consisting of 499 normotensive pregnancies. According to the obtained data, 27.7% of the women with chronic hypertension had proteinuria, 61% had bacteriuria and 58.6% had superimposed EPH gestosis. The occurrence of EPH gestosis among the controls was 5.6%, that is significantly less than in the experimental group (X2 = 282.8%; p < 0.001). The outcomes of pregnancies associated with chronic hypertension were: 19% preterm deliveries compared to the controls in which only 9.2% preterm deliveries occurred (X2 = 14.4; p < 0.001). Newborns from pregnancies with essential hypertension were significantly heavier, weighing 3177 +/- 734 g, than those from pregnancies with secondary hypertension, which weighted 2578 +/- 932 g. Perinatal mortality was higher in the study group and significantly higher in the pregnancies with associated secondary hypertension (30.3%) than in pregnancies associated with essential hypertension (15.8%).

Glucose, insulin, HGH and IGF-I levels in maternal serum, amniotic fluid and umbilical venous serum: a comparison between late normal pregnancy and pregnancies complicated with diabetes and fetal growth retardation.

Fetal growth and development is dependent upon various growth factors such as glucose, insulin, HGH and IGF-I. These growth factors were measured in maternal serum (MS), amniotic fluid (AF) and umbilical venous serum (UV) in late gestation in normal, insulin dependent diabetic pregnancies (IDDM) and in pregnancies complicated with intrauterine growth retardation (IUGR). The UV glucose values of 1.9 +/- 0.9 mmol/L and UV insulin values of 8.0 +/- 1.8 mU/L were the lowest in IUGR pregnancies, and the highest were in UV serum from IDDM pregnancies, and the difference was statistically significant for this two groups. IGF-I values in UV indicated that there was significant difference in IGF-I concentrations when both, IUGR and IDDM groups were compared to the controls. There was a parallel shift in AF and MS glucose and insulin concentration as birthweight increased. The highest IGF-I values of 7.2 +/- 9.6 mumol/L in AF and MS were found in pregnancies with infants whose birthweight was 3500 grams and greater. Infants from pregnancies complicated with IUGR and IGF-I low values of 0.6 +/- 1.2 mumol/L in AF. HGH concentrations of 15.6 +/- 9.4 micrograms/L in UV were observed in IDDM pregnancies and significantly lower than the values in IUGR and normal pregnancies. HGH umbilical venous values decreased with duration of pregnancy and with increase in fetal size. The high HGH concentrations in the fetus and its dramatic fall after parturition, and the obtained negative correlation between HGH and IGF-I in umbilical vein may exhibit the maturation of the hypothalamic-growth hormone-IGF-I axis. It seems likely that changes in maternal serum, umbilical venous and amniotic fluid insulin-like growth factor I influence birthweight in normal and IUGR infants and in those of diabetic mothers.

[Pregnancy and labor associated with encephalopathy in neonates during the early neonatal period]. / Trudnoca i porod u novorodencadi s encefalopatijom u ranom neonatalnom razdoblju.

Pregnancy complications, drugs and surgical interventions during pregnancy, fetal growth, medications and interventions during labor, labor complications as well as fetal heart activity during labor in a group of 114 term infants without malformations, but with signs of central nervous system (CNS) damage throughout early neonatal period are compared with paired group of term healthy infants born in the same presentation and mode of delivery. Among prelabor factors only maternal hypertension (found in 16.7% of encephalopathy children versus 0.8% in a control group) was significantly correlated with CNS damage. Fetal growth retardation and long term ritodrine administration were found more frequent in encephalopathy than in healthy group of infants, although statistical significance between the groups could not be demonstrated. A prolonged second stage of labor, high oxytocin dosage, too frequent uterine contractions and vacuum extractions were found significantly correlated with neonatal encephalopathy. CTG pattern during labor was normal in only 28.9% of children, with encepalopathy prepathologic in 46.4% and pathologic in 24.7%. The respective percentages for healthy newborns were: 82.5%, 16.25% and 1.2%. All differences between the groups were statistically significant. Mean duration of prepathologic CTG score in the group of infants with encephalopathy (78.8 minutes) as well as of pathologic score (51.7 minutes) was significantly longer than in healthy infants (23.7 minutes prepathologic and 7 minutes pathologic).(ABSTRACT TRUNCATED AT 250 WORDS)

[Perinatal care]. / Perinatalna zastita.

In the Republic of Croatia, the perinatal mortality, as an indicator of perinatal care, has decreased from 38.6% in 1950-54 to 10.9% in 1989 which means that today it is on the low mortality level like in the Middle- and West-European countries. The decline of perinatal mortality is especially evident after 1985. There are pronounced differences within the different regions of the Republic of Croatia, the lowest perinatal mortality is in the town of Zagreb and in the central Croatia, while the highest one in the region of Bjelovar, Slavonia and Dalmatia. Comparing the data from 29 maternity hospitals and taking into account a decrease in the number of hospitals with high perinatal mortality (48% in 1972 to zero in 1990) and an increase in the number of hospitals with low mortality (11 or 38% with mortality less than 10% in 1990), an increase of the delivery frequency completed by cesarean section was found: in 1990 there were 31% of the maternity hospitals with more than 10%, 45% with 6-10% and 24% with less than 6% of cesarean sections. Over recent years the maternity hospitals are better supplied with the necessary medical equipment: in 1990 97% of the hospitals were provided with cardiotocographs, 97% with ultrasound apparatuses and 90% with baby incubators. A sufficient number of specialists in gynecology and obstetrics is available, while there are lacking 21 specialists in pediatrics--neonatology, what is one third of the required number.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pregnancy outcome after early amniocentesis]. / Ishod trudnoce nakon rane amniocenteze.

The indications, karyotype, and outcome of 1812 pregnancies following midtrimester amniocentesis (eACZ/as) performed from 1977 to 1989 are presented, especially regarding the risk of pathologic karyotypes and spontaneous abortion. There were 37 pathologic karyotypes (trisomy 21 in 24 pregnancies). The spontaneous abortion rate following amniocentesis was 2.8% although it was almost halved after direct ultrasound guidance had been introduced (1.87% versus 3.66%). In gravidas with previous spontaneous abortion, the preterm delivery rate and spontaneous abortion rates following rACZ were significantly increased. There is a progressive increase of the spontaneous abortion rate after eACZ with the number of previous spontaneous abortions; 5.83% when there was only 1 previous spontaneous abortion, 7.83% when there were 2, and 8.75% when there were 3 or more spontaneous abortions. Previous spontaneous abortions do not increase the risk of chromosomal aberration. In women aged 37 years or more the risk of trisomy 21 is 0.69%, aged 38 years 1.55% and over 39 years 0.44%. The risk is rapidly increasing after 40 years of age (2.25%). The proportion of pathologic karyotypes in these age groups was significantly higher in comparison to younger women. The age limit of 37-38 years as the indication of a possible appearance of mid-trimester ACZ is discussed.

[Relation between fetal hypoxia, neonatal asphyxia and hypoxic-ischemic encephalopathy]. / Povezanost fetalne hipoksije, neonatalne asfiksije i hipoksicko-ishemicke encefalopatije.

Clinical data, duration of labour, mode of delivery and possibilities of fetal heart rate monitoring in predicting perinatal asphyxia and neonatal encephalopathy in 143 consecutively delivered asphyxiated infants and 143 paired healthy infants are analyzed. Perinatal asphyxia occurred in only 2.6% of normal pregnancies and significantly more frequently in pregnancies complicated by gestosis. It is far more common in children subject to operative deliveries (15-20%) and when labour lasts longer than 12 hours, either in vertex or breech presentations. The occurrence of encephalopathy is less frequent in children delivered by cesarean section (1.6%) and almost three times more frequent than in vaginal breech deliveries. In asphyxiated children delivered vaginally, significantly more frequently CTG scores were prepathologic (38% versus 3.4%). In the cesarean section group the differences are not significant in prepathologic CTG scores but are highly significant when CTG scores were pathologic (36% versus 2.7%). The mean duration of the pathologic heart rate pattern is significantly longer in mild asphyxia in comparison to the control group (45 minutes versus 12.5 minutes). In moderate asphyxia the pathologic CTG pattern lasted 72.1 minutes and in severe asphyxia 52 minutes.

[Epilepsy and pregnancy]. / Epilepsija i trudnoca.

A total of 132 women with epilepsy were confined in the period from 1978-1989. Their pregnancies and outcomes were analysed. The special aim was to find out if the anticonvulsive therapy has any correlation with the occurrence of fetal malformations in the studied group of women. In 43.9% of pregnant women with epilepsy, methyl-phenobarbitone as an anticonvulsive drug was administered, while carbamazepine was applied in 13.6% cases. A combination of phenytoin and phenobarbitone was prescribed in 18.9% of cases. Primidone was the drug of choice in 8% cases and 5.3% of patients were treated with various combinations of anticonvulsive drugs. Hyperemesis, threatened spontaneous abortion and premature labor complicated significantly more pregnancies in patients with epilepsy than on controls. Pregnancies from the studied group were terminated by the cesarean section in significantly more cases (11.2%) than in the control group (5.4%). Newborns from mothers with epilepsy had a statistically lower birthweight (3173 +/- 575 g) than those born from healthy mothers (3376 +/- 510g). Fifteen newborns or 11.2% were born with congenital malformations, while among the control group of newborns only two were malformed. It is noticed that the newborns from mothers treated with phenitoin and phenobarbitone had dysmorphic anomalies of the face more frequently. The drugs mentioned above interfere with the metabolism of K vitamin and as a result of this interreaction, mothers and newborns can suffer from coagulation disorders. In conclusion it is important to mention that no anticonvulsant drug seems to be absolutely safe when used during pregnancy since each of them has a teratogenic effect on the fetus.

[Myasthenia gravis in pregnancy]. / Miastenija gravis i trudnoca.

Twenty-nine patients with myasthenia gravis in pregnancy have been presented. These patients represent a total of 31 deliveries and 33 newborns. Despite that myasthenia gravis is an illness that poses potentially grave complications for both mother and infant, there were no maternal and neonatal deaths. Only two patients experienced significant exacerbation of their disease during pregnancy. Most of patients underwent vaginal delivery. Cesarean section is not indicated unless there are obstetrical reasons. Incidence of cesarean section delivery was 16.1%. Vacuum extractor has been used to shorten the second stage of labor and its incidence was 16.1%. In the seven (22.6%) patients myasthenic signs and symptoms got worse during the postpartal period. Neonatal myasthenia gravis was observed in 13 (39.4%) newborns. Inverse relationship was found between neonatal myasthenia and duration of disease in mothers. Incidence of neonatal myasthenia was higher in newborns born by mothers with short duration of myasthenia gravis.

[Peroral and intracervical administration of prostaglandin E2 for stimulation of term labor in premature rupture of fetal membranes]. / Peroralna i intracervikalna primjena prostaglandina E2 u stimulaciji rocnog poroda kod prijevremenog prsnuca vodenjaka.

The outcome of stimulation of labour in 219 primiparous patients with more than 6 hours following a premature rupture of the membranes, and with an ripe cervix, without the established labour, was analysed according to the mode of treatment. One hundred and thirty eight (138) women received PGE2 peroral tablets, 14 intracervical PGE2 gel, and 67 oxytocin intravenously. There were 73.2% vaginal deliveries in the group that received PGE2 per os, 77.5% in the group that received oxytocin, and 92.9% in the group that was given intracervical gel. The differences were significant. The cervix remained unripe in 9.4% patients that received PGE2 perorally, in 14.9% of those that received oxytocin, while in the gel group it became favourable in all parturients. Uterine polisistoly was encountered in 10.9% labours after peroral stimulation, in 7.1% in the gel group and in 1.5% in the oxytocin group, and perinatal asphyxia in 16.7%, 7.1% and 13.4%, respectively. When too frequent, especially if combined with oxytocin and given to patients with a moderately favourable cervix, peroral stimulation predisposes to uterine polisitoly. Intracervical application of PGE2 gel is the method of choice in primigravid patients with a premature rupture of the membranes and the unripe cervix (Bishop score O). In gravidas with a more favourable cervix (Bishop score 4-6) the administration of oxytocin is acceptable with less complications. In those with a moderately favourable cervix (Bishop score 1-4) the gel application proved to be preferable, although stimulation could be carried out as well.

[Bacterial flora in the reproductive system in the intra-amniotic infection syndrome]. / Bakterijska flora reproduktivnog sustava kod sindroma intraamnijske infekcije.

By the bacteriological aerobic analysis of the cervical swabs of 64 pregnant women with a subacute syndrome of intraamniotic infection in the 16th and 28th gestation weeks, pathogenic bacteria were isolated in 59 women (92.2%) and out of the swabs of 30 young girls with less sexual experience, 8 (26.7%) showed the presence of pathogenic bacteria, the difference being statistically highly significant (X2 V 56.9, p less than 0.001). From the ejaculates of the husbands of the same pregnant women, pathogenic bacterial were isolated in 57 of them (89.1%) and from the ejaculates of the controlled groups of young adolescents, pathogenic bacteria were isolated in 5 of them (16.7%), the difference being again statistically highly significant (X2 = 62.2, p less than 0.001). Comparing bacteria from the swabs of pregnant women with the syndrome of intraamniotic infection with those from the semen of their husbands, it has been found that the bacteria were identical in 40.6% if only one kind of bacteria was isolated and in 68.7% if several kinds of bacteria were isolated from the swab or ejaculates. In the group of 30 young girls a statistically significant dependence of pathogenic bacteria on the number of partners in their sexual life was observed (X2 = 4.54, p less than 0.05); pathogenic bacteria were isolated only once from the swabs of girls with only one partner and 6 times from the swabs of girls with two or more sexual partners.

[Prenatal diagnosis of congenital adrenal hyperplasia due to 21-hydroxylase enzyme deficiency]. / Prenatalna dijagnostika kongenitalne adrenalne hiperplazije zbog nedostatka enzima 21-hidroksilaze.

Prenatal diagnosis of the "classical" forms of congenital adrenal hyperplasia (CAH) which is a result of 21-hydroxylase (21-OH) deficiency either complete, with salt-wasting or incomplete without salt wasting, is performed in two ways: by measuring concentration of 17-hydroxyprogesterone (17-OHP) and androstendione (delta 4) in amniotic fluid and by HLA typing of fetal cells from amniotic fluid. Having ones own normal values is the basic condition for the safe prenatal diagnosis of CAH 21-OH deficiency by measuring steroid concentration in amniotic fluid. Normal concentrations of 17-OHP in amniotic fluid achieved by amniocentesis in 85 pregnant women from 16-23 gestation week have been measured, as well as concentrations of delta 4 in 66 pregnant women in the same period of gestation. It has been proved that there are no differences between the concentrations of delta 4 in amniotic fluid regarding the sex. As far as 17-OHP is concerned, the same was confirmed earlier. The results of 9 prenatal diagnosis in 8 families, having already one child with "classical" form of CAH with salt-wasting, have been presented. It was achieved by combination of two methods: by measuring concentration of 17-OHP and delta 4 in amniotic fluid and HLA typing of fetal cells from amniotic fluid. In 8 fetuses at risk the birth of healthy children was correctly predicted, which was confirmed after the birth in three cases by HLA typing and measuring concentration of 17-OHP and delta 4 and from the blood of newborn babies.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effect of treatment of bacteriuria on pregnancy outcome]. / Utjecaj lijecenja bakteriurije na ishod trudnoce.

In the period from 1972 to 1979, 3497 pregnant women were tested at the two Zagreb Health Centers. Urine cultures were taken from all women by Arneil's "dip slide" method, modified by Babic. Significant asymptomatic bacteriuria (SAB) was found at the onset of pregnancy in 10.7% cases. Pregnant women with SAB at the end of pregnancy, in comparison to those whose urine was sterile, had significantly more children weighing under 1000 g at birth (1.3% v. 0.2%; x2 = 8.44, p less than 0.01) and under 2500 g (6.5% v. 3.8%; x2 = 3.95, p less than 0.05), more deliveries by vacuum extraction (3.0% v. 1.3%; x2 = 4.62, p less than 0.05), and a significantly higher perinatal mortality (64.9 v. 15.6; x2 = 24.73, p less than 0.001). The treatment of SAB at the very beginning of pregnancy significantly decreased, by a fourth (25.5%), its frequency at the end of pregnancy. This figure is almost twice as high in those not treated (46.1%, x2 = 16.64, p less than 0.001). SAB treatment contributed to a significantly lower frequency of hypertension at the end of pregnancy (8.9%) in comparison to non-treated cases (31.4%, x2 = 29.45, p less than 0.001).