Cancer during pregnancy: Twenty-two years of experience from a tertiary referral center.

INTRODUCTION: Cancer complicating pregnancy is a rare but potentially life-threatening condition for both the mother and her child. The aim of the present study was to assess the outcomes for mothers and children after pregnancy complicated by malignancy and to investigate which parameters are important for their 1-year survival. MATERIAL AND METHODS: The study included 84 pregnant women diagnosed with malignant tumors during pregnancy from 2001 to 2022. The pregnancy course and outcome, as well as parameters that could influence the survival and condition of the mother and child were evaluated. Mothers and children were followed up for 1 year after delivery to assess their condition/complications and overall survival. RESULTS: Most malignancies were gynecological (31%) or hematological (23.8%) and were diagnosed and surgically treated in the second trimester. Most children (69%) showed adequate growth and development throughout pregnancy but were delivered before term (53.6%) to allow mothers to receive therapy. Adjuvant therapy during pregnancy mostly caused a transitory deterioration of the child's condition, while surgery did not significantly impact the pregnancy course. Deliveries, on average, occurred during the 33.01 ± 6.16 gestational week (range: 20-40) and mostly by cesarean section (76.2%). For mothers, the pregnancy survival rate was 95.2% and survival after 1 year was 87.5%. However, 37.5% of women were still ill and required additional therapy 1 year postpartum. The pregnancy survival rate for children was 94%, whereas the 1-year survival rate was 76.2%. Most children had a favorable condition (alive, adequately growing and developing, and without complications) at birth (81%) as well as at the 1-year follow-up (63.7%). Regression analysis identified the following predictors of favorable 1-year maternal condition: applying therapy during pregnancy, no progression of the malignancy during pregnancy, and delivery at a later gestational week. Predictors of favorable 1-year condition of children were lower histopathological grade of malignancy, surgery as therapy for malignancy, obtaining higher birthweight, and delivery by cesarean section. CONCLUSIONS: If the malignancy is not progressing, pregnancy should be continued as long as possible for the child to obtain adequate birthweight. Both surgery and chemotherapy were safe therapeutic choices, as most pregnancies continued successfully after therapy.

Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study.

Introduction: The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. Materials and methods: The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. Results: The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. Conclusion: The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.

Severe Hemoperitoneum due to Ovarian Bleeding after Transvaginal Oocyte Retrieval with Surgical Management: A Retrospective Analysis and Comprehensive Review of the Literature.

Background and Objectives: Severe hemoperitoneum of ovarian bleeding origin is a rare but potentially life-threatening complication of transvaginal oocyte retrieval (TVOR) procedure. The study aimed to present a case series of surgically managed patients from our clinic with hemoperitoneum caused by ovarian bleeding after TVOR, as well as to perform a comprehensive literature review in order to summarize and analyze all published cases with this condition and their management. Materials and Methods: The data of 2939 patients, who underwent TVOR procedures for IVF/ICSI (in vitro fertilization, intracytoplasmic sperm injection) in our clinic between 2010 and 2021 were reviewed. Moreover, a systemic literature search was performed. Main outcome measures from the pooled analysis were incidence and risk factors, type of surgery, intraoperative finding and intervention leading to hemostasis. Results: In our Clinic 4 (0.136%), cases of hemoperitoneum due to ovarian bleeding were surgically managed. Moreover, 39 cases from 18 studies reported in the literature were identified. No risk factors besides lean women with PCOS were identified. In the pooled analysis, the bleeding symptoms appeared in 58.1% of patients within eight hours after TVOR and cumulatively in 81.4% cases during the 24 h after TVOR. The average time from TVOR to surgery was 27.19 ± 53.25 h. Hemostasis was mostly established using electrocoagulation, although few cases of ovariectomy were also reported. Embryo transfer at 60% of cases was postponed and embryos cryopreserved. Conclusions: Severe hemoperitoneum due to ovarian bleeding after TVOR is a rare event that should be treated by techniques of minimally invasive surgery whenever possible. Protocols should be developed to enable optimal management strategies for infertility patients. Embryos obtained should be cryopreserved.

Accuracy of IOTA Simple Rules, IOTA ADNEX Model, RMI, and Subjective Assessment for Preoperative Adnexal Mass Evaluation: The Experience of a Tertiary Care Referral Hospital.

OBJECTIVES: The aim of this study was to evaluate the accuracy of IOTA Simple Rules (SR), IOTA ADNEX model, Risk of Malignancy Index (RMI), and subjective assessment (SA) which is used for adnexal mass assessment in our institution. DESIGN: This is a prospective observational study. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included patients with at least one adnexal mass who needed elective surgical evaluation based on clinical and laboratory findings. Patients admitted to Clinic for Gynecology and Obstetrics, University Clinical Center of Serbia, were recruited for the study between January 2019 and June 2021. Level II ultrasonographers performed a gray scale and Doppler exam for each patient. Preoperative classification of adnexal masses (benign or malignant) was performed by SA, the International Ovarian Analysis Group (IOTA) SR, IOTA ADNEX model, and Risk of Malignancy Index (RMI). Postoperatively obtained histological findings were used as a reference. RESULTS: During the study period, we enrolled 179 premenopausal and 217 postmenopausal patients, representing 396 patients in our sample. Prevalence of malignant disease in pre- and postmenopausal groups was 16.2% (29/179) and 41% (89/217), respectively. Malignant disease was diagnosed in 29.8% (118/396) of patients. SA achieved the highest discrimination accuracy between benign and malignant tumors (area under the curve [AUC] of 0.928, 95% CI [0.898-0.952]). For SA, the overall diagnostic accuracy, sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were 91.4%, 88.1%, 92.8%, 12.25, and 0.13. The AUC for Simple Rules with subjective assessment in inconclusive cases (SR + SA) was 0.912 (95% CI [0.880-0.938]). Regarding SR + SA, diagnostic accuracy, sensitivity, specificity, LR+, and LR- were 92.4%, 88.1%, 94.2%, 15.31, and 0.13. The ADNEX model had the AUC of 0.914 (95% CI [0.882-0.940]). Binary classification using the ADNEX model at a cut-off value of 10% for malignancy had the sensitivity, specificity, LR+ and LR- of 92.4%, 73.0%, 3.42, and 0.10. This resulted in the lowest overall accuracy of 78.8%. The AUC for RMI was 0.854 (95% CI [0.815-0.887]), with overall accuracy, sensitivity, specificity, LR+ and LR- of 82.3%, 73.7%, 86.0%, 5.26, and 0.31. There was no difference in the AUCs of the SA and IOTA models for the whole group, premenopausal, and postmenopausal groups. RMI performed worse compared to SA and the IOTA models. The ADNEX model achieved the highest accuracy at the cut-off value of 35%. LIMITATIONS: The data generalizability is limited by a single institution-dependent sampling. CONCLUSIONS: The IOTA SR and ADNEX model were reliable and comparable with the SA and performed better than the RMI. The IOTA SR model offers the potential for immediate and reliable diagnosis, even in the hands of less experienced ultrasonographers. Both IOTA models studied can be a valuable adjunct to a clinician's decision-making process.

Cesarean myomectomy in modern obstetrics: More light and fewer shadows.

The study aim was to evaluate management of myomas during cesarean section, the pro and cons and the outcomes of cesarean myomectomy. Moreover, we tried to investigate the long-term outcomes of cesarean myomectomy. The authors conducted a literature review using scientific databases, focusing on the benefits and outcomes of cesarean myomectomy and the recent trends regarding this topic, and identified relevant articles, related references and other papers citing them. Despite the demonstrated advantages of cesarean myomectomy, postponed myomectomy after cesarean section was recommended in some instances. Apart from recent reports on the safety and feasibility of cesarean myomectomy, the current literature also describes serious complications of cesarean myomectomy, including even maternal death. This poses a question about the reported rate of complications: whether it is underestimated in common practice. Although some studies strongly suggest the safety of cesarean myomectomy, data on the long-term outcomes of cesarean myomectomy in women are lacking. The risk-benefit ratio of cesarean myomectomy should be re-evaluated in the new century, given the increasing patient age, incidence of myoma in pregnancy, and the wide use of assisted reproductive techniques.

Epidural anesthesia can block the negative effects of prostaglandin mediators during prostate surgery.

INTRODUCTION: Inflammation plays a key role in the development of benign prostatic hyperplasia. Prostaglandin E2 (PGE2) is an important inflammation factor found in enlarged prostatic tissue that can be the main cause of inflammatory pain. The aim of this study was to investigate whether epidural anesthesia can block the negative effects of prostaglandin mediators during prostate surgery. MATERIALS AND METHODS: The study included 60 patients who underwent open prostatectomy. All patients were randomly allocated to one of two study groups. The first group received general anesthesia and the second group a combination of general and epidural anesthesia. Main outcome measures were plasma concentration of PGE2, adrenaline, noradrenaline, and dopamine, before induction of anesthesia and at the time of enucleation. RESULTS: Preoperative serum concentrations of PGE2 were high in both groups. During enucleation, serum concentrations of adrenaline, noradrenaline, and dopamine increased, followed by a rise of systolic and diastolic blood pressure in the group of patients that received only general anesthesia. Serum concentration of PGE2 was at the same level as before induction of anesthesia in both groups. CONCLUSION: Epidural anesthesia blocks transmission of painful stimulus through the spinal cord caused by prostaglandin release and prevents the rise of catecholamines and blood pressure. Open prostatectomy can become a safer procedure performed under a combination of general and epidural anesthesia. Negative intraoperative effects of inflammatory prostate mediators during other techniques for prostate surgery could also be blocked with epidural anesthesia.

Preoperative evaluation of patients with history of allergy.

The prevalence of allergic reactions in general opulation shows a constant rise. It has been estimated that up to 40% of surgical patients have a positive history of some kind of allergy. These patients represent a challenge during perioperative evaluation, since they can be exposed to a large variety of drugs and substances during surgery and anesthesia. A lot of adverse drug reactions show similar clinical presentation with allergic reactions. The latter are usually poorly explored since preoperative allergology testing is performed in a limited number of patients. Management of patients with history of allergy is impeded by the fact that most of allergens cross-react in a manner that is not always easy to predict. Allergies can manifest themselves with a broad spectrum of clinical symptoms, ranging from mild skin symptoms such as itch and urticaria, to a life-threatening anaphylactic reactions followed by hypotension, bronchospasm and cardiovascular collapse. Prevention of allergic reactions during perioperative period requires detailed history taking in order to identify patients at risk, optimization of anesthesia strategy, pharmacological premedication and further allergology diagnostic work-up in selected cases.

Preoperative preparation of pregnant women.

All the elective surgeries are to be avoided during pregnancy and pregnant women should undergo only emergency surgical interventions. Pregnancy is associated with different physiological changes in the organism, which should be taken into account in preparative preparation of the pregnant women. Expanded body fluid volume leads to dilutional anemia, however other hematological disorders may be present as well. Extreme obesity is a frequent comorbidity, while hypertension is associated with the highest risks since it may lead to a life-threatening complication--eclampsia. As for other coexisting diseases, urinary tract infections and gestational diabetes are the most common as well as hyperthyroidism and other diseases that may also develop. The type and severity of the acute surgical disease, extensiveness of the planned surgery as well as the type of planned anesthesia to be applied, occasionally necessitate, depending on the gestational age, termination of pregnancy to be considered. Gynecological-obstetric consultations are mandatory in all surgical interventions planned in pregnant women.

Topical glycopirrolate for the management of hyperhidrosis in herpetic neuralgia.

Herpes zoster is a relapse of varicella. In certain cases, long-term pain and hyperhidrosis have been noted. Appearance of herpes zoster during pregnancy is infrequent. We described hyperhidrosis and pain treatment using glycopirrolate cream in a pregnant woman with herpetic neuralgia. A 32 year old woman, 21 weeks pregnant with second child, complained to her gynecologist of the appearance of a vesicular rash on the left half of the forehead that progressed toward her left eyelid, accompanied by lancinating pain, allodynia, hyperhidrosis and small edema, blepharitis and conjunctivitis. Following clinical and laboratory tests, she was diagnosed with herpes zoster ophtalmicus. Aciclovir therapy was administered 800 mg orally five times daily for seven days. Pain therapy was initiated with amitriptilline. We discontinued amitriptilline therapy after 10 days because of appearance of unwanted side effects. After skin changes ceased, we introduced Lidocaine patch into pain therapy which reduced the allodynia, but not the lancinating pain and hyperhidrosis. At that time we began using glycopirrolate cream which reduced pain intensity by 28.5% within 24 hours, and completely eliminated hyperhidrosis. After 48 hours of use, the pain completely disappeared. During the Glycopirrolate cream therapy, there were no side effects. This is a first report to document that a topical Glycopirrolate cream has a beneficial effect in a patient with hyperhidrosis and herpetic neuralgia.