Severe Early-Onset Intrahepatic Cholestasis of Pregnancy Following Ovarian Hyperstimulation Syndrome with Pulmonary Presentation after In Vitro Fertilization: Case Report and Systematic Review of Case Reports.

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-related liver disease, usually presented in the third trimester with pruritus, elevated transaminase, and serum total bile acids. Evidence shows that it can be developed in the first trimester, more commonly after in vitro fertilization (IVF) procedures, with the presence of ovarian hyperstimulation syndrome (OHSS). METHODS: A literature search was conducted in the PubMed/MEDLINE database of case reports/studies reporting early-onset ICP in spontaneous and IVF pregnancies published until July 2023. RESULTS: Thirty articles on early-onset ICP were included in the review analysis, with 19 patients who developed ICP in spontaneous pregnancy and 15 patients who developed ICP in IVF pregnancies with or without OHSS. Cases of 1st and 2nd trimester ICP in terms of "early-onset" ICP were pooled to gather additional findings. CONCLUSIONS: Proper monitoring should be applied even before expected pregnancy and during IVF procedures in patients with known risk factors for OHSS and ICP development (patient and family history), with proper progesterone supplementation dosage and genetic testing in case of ICP recurrence.

Expression of EGF, EGFR, and proliferation in placentas from pregnancies complicated with preeclampsia.

OBJECTIVE: To investigate proliferation, EGF and EGFR expression of villous trophoblast (VTB), decidual cells (DC), and extravillous trophoblast (EVTB) in the placentas from pregnancies complicated with preeclampsia (PE) and to compare them with placentas from normal pregnancies. METHODS: Twenty-nine PE placentas and 19 control placentas were studied for EGF and EGFR immunohistochemical expression (noted as week, moderate or strong). Proliferation was expressed as the proliferation index. The CK7 antibody was used to distinguish DC from EVTB. RESULTS: DC and EVTB proliferation was significantly higher in PE placentas. EGFR and EGF expression showed no significant difference. CONCLUSION: Higher DC and EVTB proliferation in PE could contribute to PE development.

Pregnant women's knowledge and attitudes to prenatal screening for fetal chromosomal abnormalities: Croatian multicentric survey.

We aimed to assess opinion and preferences of Croatian pregnant women regarding the prenatal screening tests for trisomies. The study was conducted in Zagreb, Split, Cakovec, Nova Gradiska, Gospic and Zlatar. It was organized in the public primary healthcare centers, among the pregnant volunteers during their first visit to an antenatal clinic (7-12 weeks pregnant). The respondents filled anonymous questionnaire reflecting their knowledge and attitudes to the screening options. In total, 437 completed questionnaires were selected. The average maternal age and the level of education differed significantly between the respondents in the respective cities (P < 0.001). Of the respondents with positive attitude towards screening, the majority would prefer the first-trimester combined test (160/219; 73.1%), while 37/219 (16.9%) opted for the second-trimester biochemical screening. The remaining 22/219 (10.0%) would accept only the ultrasound screening. Among the 224 respondents, who would accept the combined first-trimester test, 95 (42.4%) held a college and university degree, whereas among 59 women, who would choose the second-trimester biochemical screening, 14 were highly educated (23.7%). The difference was statistically significant (P = 0.016). The univariate regression analysis showed that age, level of education and previous information were significant variables predictive for the choice of the test; the level of education and previous knowledge remained significant in the multivariate model. The survey has revealed some of the points that should be improved in the future concept of screening program in Croatia. Health professionals should persist to mend women's knowledge about prenatal screening, taking into consideration women's preferences as well.

Ki-67 quantitative evaluation as a marker of cervical intraepithelial neoplasia and human papillomavirus infection.

OBJECTIVE: To assess the value of Ki-67 quantitative analysis in cervical intraepithelial neoplasia (CIN) in relation to CIN grading and human papillomavirus (HPV) group typing. METHODS: Cervical samples selected retrospectively from 106 cases were analyzed immunohistochemically for Ki-67-positive nuclei in 3 epithelial layers and by polymerase chain reaction for HPV typing. RESULTS: The proportion of high-risk HPV positivity was 0% in normal controls and 30% in CIN 1, 57% in CIN 2, and 90% in CIN 3 groups, and there was no low-risk HPV finding in CIN 2 and CIN 3 cases (P < 0.001). High-risk HPV-positive cases exhibited significantly more Ki-67-positive nuclei per 100-mum basal membrane, which were more frequent in the middle and upper third layers of the epithelium compared with low-risk HPV and HPV-negative cases (P < 0.001). The differences among the CIN groups in the total number and in the percentages of Ki-67-positive nuclei in the lower, middle, and upper third layers of the epithelium were significant (P < 0.001). With the cutoff value of more than 33% Ki-67-positive nuclei in the middle and the upper third layers of the epithelium, Ki-67 staining demonstrated 98.4% sensitivity (60/61 cases) and 97.8% specificity (44/45 cases) for the detection of CIN 2/CIN 3 in our study group. CONCLUSIONS: The Ki-67 immunostaining proved to be predictive for high-risk HPV infection, and it can differentiate reactive lesions from cervical dysplasias. Ki-67 quantitative analysis in 3 epithelial layers is a sensitive and specific method of differentiation between CIN 1 and CIN 2/CIN 3 grades and can be a valuable adjunctive method for more accurate CIN grading.

Elevated second-trimester free beta-hCG as an isolated finding and pregnancy outcomes.

OBJECTIVE: To investigate the relationship between unexplained elevated second-trimester free beta-human chorionic gonadotropin (beta-hCG) levels and pregnancy complications as well as adverse pregnancy outcomes. METHODS: The study cohort comprised 2,110 non-smoking women with chromosomal and structurally normal fetuses at low-risk for both Down's syndrome (risk <1:250) and neural tube defects (maternal serum alpha-fetoprotein <2.0 MoM). A free beta-hCG value of > or =2.0 MoM was used to define the populations with elevated levels of free beta-hCG. Descriptive statistics, chi2 test, Fisher's exact test, and logistic regression analysis were used for statistical analysis, and p < 0.05 was considered statistically significant. RESULTS: The mean maternal age of the study group was significantly lower than in controls (27.9 +/- 4.3 and 30.6 +/- 5.1 years, respectively, p < 0.05), while the proportion of primigravidas was significantly higher compared to that of controls (p < 0.05). After adjustment of the 2 groups according to maternal age and parity, we observed an increased incidence of preeclampsia among women with elevated free beta-hCG levels in relation to controls (p < 0.05). However, a logistic regression analysis demonstrated that the free beta-hCG level was not a predictor of the occurrence of preeclampsia. No significant relationship was found with the incidence of gestational diabetes, oligohydramnios, polyhydramnios, pregnancy-related hypertension, intrauterine growth retardation, preterm delivery, spontaneous abortion and stillbirths (p > 0.05).

Gestational age--the most important factor of neonatal ponderal index.

Ponderal index (fetal weight in grams X 100 / (fetal length in centimeters)3) (PI) is one of the anthropometric methods used to diagnose impaired fetal growth. Irrespective of the infant's position on the growth-weight-for-gestational age charts, PI is low in malnourished infants and high in obese ones. As fetal growth is affected by ethnicity, geographic location and socioeconomic status, we developed standards for neonatal PI, and assessed the effects of gestational age, sex and maternal parity. Data on 5798 newborns from singleton pregnancies born in the Department of Gynecology and Obstetrics, Split University Hospital, were retrospectively analyzed. Over a 15-month period in 2000/2001, 5596 newborns from 24 to 42 weeks of gestation were born. The other 202 newborns, born from 24 to 34 weeks of gestation in the ten year period, 1990-1999, were added because of the small number of preterm infants; ensuring a minimum of 30 to fill up at least infants in each gestational week. All mothers were of Caucasian origin. Stillbirths and fetuses with congenital malformations were excluded. The 10th, 50th and 90th percentiles, mean values with standard deviation of PI and the 10th, 50th, and 90th percentiles of birth weight and birth length are presented separately at weekly intervals. PI showed linear correlation with gestational age from 24 to 39 weeks, after witch the data plateaued. Sex and parity had no impact on PI in infants born between 24 and 37 weeks. Analysis of variance revealed PI to be significantly higher in female than in male newborns, and in multiparous than in nulliparous infants after 37 weeks of gestation. In conclusion, gestational age is the most important factor of neonatal PI. The effects of sex and parity on PI should only be considered in term neonates.

Gestational Age - the Most Important Factor of Neonatal Ponderal Index

Ponderal index (fetal weight in grams x 100 / (fetal length in centimeters) 3) (PI) is one of the anthropometric methods used to diagnose impaired fetal growth. Irrespective of the infant's position on the growth-weight-for-gestational age charts, PI is low in malnourished infants and high in obese ones. As fetal growth is affected by ethnicity, geographic location and socioeconomic status, we developed standards for neonatal PI, and assessed the effects of gestational age, sex and maternal parity. Data on 5798 newborns from singleton pregnancies born in the Department of Gynecology and Obstetrics, Split University Hospital, were retrospectively analyzed. Over a 15-month period in 2000/2001, 5596 newborns from 24 to 42 weeks of gestation were born. The other 202 newborns, born from 24 to 34 weeks of gestation in the ten year period, 1990-1999, were added because of the small number of preterm infants; ensuring a minimum of 30 to fill up at least infants in each gestational week. All mothers were of Caucasian origin. Stillbirths and fetuses with congenital malformations were excluded. The 10th, 50th and 90th percentiles, mean values with standard deviation of PI and the 10th, 50th, and 90th percentiles of birth weight and birth length are presented separately at weekly intervals. PI showed linear correlation with gestational age from 24 to 39 weeks, after witch the data plateaued. Sex and parity had no impact on PI in infants born between 24 and 37 weeks. Analysis of variance revealed PI to be significantly higher in female than in male newborns, and in multiparous than in nulliparous infants after 37 weeks of gestation. In conclusion, gestational age is the most important factor of neonatal PI. The effects of sex and parity on PI should only be considered in term neonates.

[Does the suture material and technique have an effect on healing of the uterotomy in cesarean section?]. / Utjecu li materijal i tehnika sivanja na cijeljenje uterotomije pri carskome rezu?

The aim of the study is to present the influence of different suturing techniques and different materials (catgut plain, Dexon and Vicryl) on healing of lower transverse uterotomy (in further text uterotomy) in Cesarean section (CS). Uterotomies were sutured by four ways: one row interrupted (group A), one row continuous (group B), two rows interrupted (group C), two rows interrupted and continuous (group D). Uterotomies were classfied according to the material used for suturing into the catgut group, Dexon group and Vicryl group. Between January 1983 and December 2001 out of 7830 CSc 1946 (24.8%) patients had repeat deliveries: 1059 (55.0%) had a vaginal delivery and 887 (45.0%) repeat CS. In the same period out of 1946 deliveries 15 (0.8%) uterine ruptures-dehiscences (URD) were diagnosed. In catgut group out of 302 deliveries 11 (3.6%) URD were registered: nine (7.2%) in group D (N = 125) and two (1.7%) in group C (N = 20). No URD was diagnosed in group A (N = 57). In Dexon group (N = 226) URD were diagnosed regardless of the method of suturing the uterotomy. In Vicryl group out of 1486 deliveries four (0.28%) URD were registered: one (0.16%) in group A (N = 615), one (0.3%) in group B (N = 333), one (0.52%) in group C (N = 190) and one (0.35%) in group D (N = 280). The best uterine scar is the one after using one layer interrupted Vicryl and Dexon suture. The worst healing results were obtained after two-row interrupted and continuous sutures using catgut.

Fetal reduction in multifetal pregnancy--ethical dilemmas.

As a result of the increased use of drugs that enhance fertility, and the advent of in vitro fertilization and embryo transfer over the last 2 decades, the incidence of multifetal pregnancies has increased exponentially. In parallel with this increase methods of care for women carrying multiple fetuses have become more complex and well developed. Importantly, it has become obvious that in the case of such pregnancies the rates of mortality and morbidity of both fetuses and mothers, particularly in cases where four or more fetuses are involved, are extremely high. Improvements in the techniques of assisted fertilization should result in fewer iatrogenic multifetal pregnancies and a commensurate decrease in related risks. Fetal reduction seems to be an acceptable method of improving maternal and fetal outcome in high order multiple pregnancies despite the many unresolved medical and ethical dilemmas.