A Survey of Current Prophylactic Treatment for Ophthalmia Neonatorum in Croatia and a Review of International Preventive Practices.

BACKGROUND Ophthalmia neonatorum, or neonatal conjunctivitis, is an acute infection that occurs within the first 28 days of life. This aim of this survey was to evaluate the current methods of preventive treatment for ophthalmia neonatorum in maternity hospitals in Croatia. MATERIAL AND METHODS The annual hospital birth rate in Croatia is approximately 40,000. A clinical survey was undertaken with data collected using questionnaires sent to all 32 maternity hospitals in Croatia. There was a 100% response rate to the questionnaires. RESULTS Preventive treatment for ophthalmia neonatorum was administrated to all newborns in 75% (24/32) of Croatian maternity hospitals. In 45.8% of maternity hospitals, (11/32) these procedures were performed within the first hour after birth. In 54.2% of maternity hospitals (13/32), preventive treatment for ophthalmia neonatorum was administrated to all newborns from one to three hours after birth. The main treatment agent was tobramycin (83.3%). Other topical prophylactic treatments included povidone-iodine (8.3%), erythromycin (4.2%), and silver nitrate (4.2%). In 25% of obstetric units, prophylaxis for ophthalmia neonatorum was not used routinely, but in cases of diagnosed neonatal conjunctivitis, antibiotic treatment with tobramycin was mainly used. CONCLUSIONS A survey of all 32 maternity hospitals in Croatia showed variation in the prevalence of preventive treatment for ophthalmia neonatorum and the methods used. These findings support the need to implement standardized preventive measures that both conform to international clinical guidelines and recognize treatment availability in Croatia, where topical povidone-iodine is currently preferred for the prevention of ophthalmia neonatorum.

Effect of Delivery and Episiotomy on the Emergence of Urinary Incontinence in Women: Review of Literature

Episiotomy is obstetric procedure during which the incision extends the vestibule of the vagina during the second stage of labor. Episiotomy was extensively spread with gradual increase of rates in the first half of the 20th century and was performed medio-laterally in all nulliparous women with the idea to protect fetal head from trauma and pelvic floor from injuries. However, reports claiming that episiotomy had no such benefits were published. It was shown that routine medio-lateral episiotomy did not protect against the appearance of urinary incontinence after vaginal delivery, while the risk of anal incontinence could be increased. The role of episiotomy in development of pelvic floor dysfunction remains quite unclear. Due to the mentioned reason, restricted episiotomy approach should be accepted. The origin of stress incontinence during pregnancy is controversial and not definitely scientifically proven. Pregnancy per se and older age at first delivery may have impact on the onset of pelvic floor dysfunction. Urinary incontinence in pregnancy increases the risk of later urinary incontinence, both postpartum and later in life. Vaginal delivery is just one of the potential risk factors for development of urinary incontinence. Mechanical pressure by fetus on the pelvic floor structures, limited denervation of the pelvic floor and soft tissue damage during delivery are some of explanations for the onset of stress urinary incontinence. On the other hand, cesarean delivery might not be protective against emergence of urinary incontinence. Further research in this field is needed.

Efficacy of sling procedures for treatment of female stress urinary incontinence.

The aim of this study was to determine the efficacy and surgical outcome of the sling procedures in stress incontinent women in comparison to conventional anterior colporrhaphy. Total of 56 patients with stress urinary incontinence (SUI) were treated with sling procedure between November 2011 and March 2013, 39/56 (69.6%) with suprapubic arc (SPARC) and 17/56 (30.4%) with MiniArc method. During the same period total of 49 patients with SUI were treated with traditional anterior colporrhaphy according to Bagovid method as the control group. All patients were prospectively clinically assessed over aperiod of 3, 6 and l2 months after surgery. The objective cure rate after the follow-up was 92.9% (52/56) in observed group of patients and 79.6% (39/49) in control group and improvement was occurred in rest of 5.4% (3/56) and 18.4% (9/49), respectively (p < 0.05). The overall complications rate was significantly lower in the observed group of patients than in the control group, 12.5% (7/56) vs. 28.6% (14/49), (p < 0.05). In the sling group was postoperatively noticed slightly higher rate of urinary incontinence, but in the colporrhaphy group was emphasized rate of urinary retention. Only one from the each group of patients failed the surgical procedure and required additional correction for SUI. The mean operating time for SPARC and MiniArc procedure was 19 +/- 7 and 9 +/- 5 minutes, respectively (p < 0.0001). Mean duration of hospitalization was significantly shorter in the sling group of patients (2.6 +/- 1.0, range 2-7) days than in the control group of (9.6 +/- 1.8, range 6-18), (p < 0.001 < 0.0001). According to presented results, sling is a highly effective method in patients with SUI with low incidence of perioperative complications, promising long-term results and high patient's satisfaction.

Asymmetric neonatal crying: microdeletion, infection or birth injury?--a case report.

Asymmetric neonatal crying is a rare minor congenital abnormality caused by unilateral agenesis or hypoplasia of depressor anguli oris muscle and depressor labii inferioris muscle. It is either an isolated clinical finding or one of the clinical findings included in several malformation syndromes linked to a microdeletion within a chromosomal region 22q11.2. Some malformations in that region are associated with serious cardiovascular anomalies. Nowadays, standard diagnostic techniques for detecting aberrations within the chromosomal region 22q11.2 are fluorescence in situ hybridization (FISH) and multiplex ligation probe amplification (MLPA). This short report describes an eutrophic female newborn whose both lip corners are symmetrically positioned while at rest; while crying, left lip corner and left half of the lower lip are falling. She also has partial bilateral syndactyly between second and third toe, open foramen ovale and by ultrasound detected hyperechogenic region in the thalamus and brain parenchyme. Aiming to investigate etiopathogenesis of the newborn asymmetric crying and accompanying minor abnormalities, we have tried to verify or exclude: microdeletion syndrome, TORCH infection and birth injury. Recognising such a paresis soon after the delivery is of great importance and can be helpful in detecting other accompanying anomalies, especially cardiovascular anomalies.

Intermittent epidural TOP-UPS vs. patient control epidural analgesia during labor.

Pain during labor and delivery is often very unpleasant and stressful for the parturients. Patient controlled epidural analgesia (PCEA) has been found to be both safe and effective, providing optimal pain relief and allowing women to participate in their own analgesia). Compared to other epidural techniques, intermittent epidural top-ups and continuous epidural analgesia (CEA), PCEA uses diluted local anesthetic solutions with less motor block and less unscheduled clinician interventions. The purpose of our study was to compare intermittent bolus epidural top-ups and PCEA in labor. Sixty ASA I patients who requested epidural analgesia for labor and had written consent were included in the study. 30 patients in the first group received intermittent bolus epidural top-ups, while patients in the second group received PCEA. We evaluated duration of labor, maternal sense of pain using VAS scale and maternal satisfaction during fetal descent in both groups. We found that the duration of labor was significantly shorter and maternal sense of pain was lower in the PCEA group than in the group receiving epidural bolus top-ups. There were no differences between groups in maternal satisfaction during fetal descent.

Clear cell variant of urothelial carcinoma in urinary bladder; a clinicopathological and immunohistochemical study--a case report.

The clear cell variant urothelial carcinoma of urinary bladder is very rare and unusual neoplasm defined histologically by clear cell pattern and glycogen-rich cytoplasm. Our case of clear cell carcinoma was diagnosed with immunohistochemistry stain. A 72-year-old man, presented with painless macroscopic hematuria in November 2007. Evaluation revealed papillary tumor in urinary bladder. A transurethral resection of the bladder tumor (TUR-Bt) was performed. Histopatologic evaluation showed superficial transitional cell carcinoma and carcinoma in situ. On three month follow-up, a solitary pedunculated tumor was detected again in the left wall of the urinary bladder. A repeated transurethral resection of the bladder tumor (reTUR-Bt) was performed in February 2008. The pathological diagnosis was difficult due to diffuse clear cell appearance. Immunohistochemistry stain showed urothelial carcinoma and finally it was diagnosed as clear cell variant. Urothelial carcinoma has many variants that show a variety of appearances and characteristics. These should be well known for evaluation and optimal treatment.

Outcome and efficacy of a transobturator polypropylene mesh kit in the treatment of anterior pelvic organ prolapse.

OBJECTIVE: To report the efficacy and complications of anterior pelvic organ prolapse (POP) repair with mesh placed through the transobturator route (Perigee system; AMS, Minnetonka, MN, USA). METHODS: In total, 198 women with anterior POP grade II or higher according to the POP Quantification (POP-Q) system were treated with the Perigee procedure. The primary outcome was defined as anterior POP grade I or lower at 12 months' follow-up. The secondary outcomes included the incidences of perioperative, mesh-related, short-term, and long-term postoperative complications. RESULTS: The cure rate was 92.9% overall and 90.6% among women who had previously undergone a hysterectomy or a traditional anterior colporrhaphy. The mean POP-Q Aa and Ba values were significantly improved after the procedure (Aa 2.2 cm [0.0 to 3.0 cm] versus -2.1cm [-3.0 to -1.2 cm]; Ba -2.5 cm [-1.0 to 4.2 cm] versus -2.2 cm [-5.5 to -1.0 cm]; P<0.001). Vaginal or bladder erosions were observed in 3 patients. Other short- and long-term complications were infrequent and not statistically significant. CONCLUSION: The Perigee procedure is effective in the treatment of anterior POP and does not have serious complications even among women with previous hysterectomy or traditional anterior colporrhaphy.

[Pregnancies and deliveries in patients with Charcot-Marie-Tooth disease]. / Trudnoca i porodaj u bolesnica s hereditarnom senzomotornom polineuropatijom (Charcot-Marie-Tooth).

Hereditary motor sensory neuropathy (HMSN), also known as Charcot-Marie-Tooth (CMT) disease, is a spectrum of disorders caused by a specific mutation in one of several myelin genes, which results in defects in myelin structure, maintenance and formation. Affected individuals show progressive distal limb atrophy and weakness, often with gait disturbance and deformity of feet and hands. There have been few studies on how CMT disease can affect pregnancy, birth and the newborn. CMT is an independent risk factor for complications during pregnancy and delivery. Patients with CMT have more operative deliveries, malpresentations and postpartum bleeding than the general obstetric population. It is not clear whether the increased prevalence of malpresentation is related to fetal disease, although the disorder typically does not present until later in childhood. Postpartum bleeding from atony may be related to the disease effect on uterine adrenergic nerves. Exacerbation of CMT disease can occur in pregnancy, an effect that may be mediated by increased plasma progesterone level. Observations in an animal model were consistent with these findings as the administration of progesterone resulted in a more progressive neuropathy, while a progesterone antagonist slowed the disease progression. We treated two patients with CMT (type 5 and type X1) at our Department. Both of them had normal course of pregnancy until delivery. Emergency cesarean section was performed in both cases; in one because of malpresentation, contracted pelvis and signs of impending fetal asphyxiation during the second stage of delivery, and in the other one based on neurologist indication. In the latter, uterine atony with profuse postpartum bleeding occurred immediately after cesarean section and emergency hysterectomy was performed according to clinical status.

Expression of matrix metalloproteinase-1 in uterosacral ligaments tissue of women with genital prolapse.

Collagen metabolism is altered in the pelvic organ tissues of women with genital prolapse. The aim of this study was to compare collagen metabolism by measuring matrix metalloproteinase-1 (MMP-1) expression in uterosacral ligament tissues of postmenopausal women with and without genital prolapse. Uterosacral ligament tissues were obtained at the time of abdominal or vaginal surgery from twenty-four patients with pelvic organ prolapse (POP) and 21 women who underwent gynecologic surgery for benign indications. The tissue samples were analyzed by immunohistochemistry. There were no differences in age, BMI and parity between two groups. The patients with genital prolapse demonstrated significantly higher occurences of MMP-1 expression compared to controls. These findings indicate that increased MMP-1 expression in uterosacral ligaments is associated with genital prolapse. Our data are consistent with the theory that increased collagen breakdown may play an important role in the onset and development of pelvic organ prolapse (POP).

Preoperative clonidine or levobupivacaine--effect on systemic inflammatory stress response.

With perioperative pain control it is possible to supervise immune system, release of inflammation mediators, and influence on treatment outcome. Use of analgetics before the pain stimulus (preventive analgesia) obstruct development of neuroplastic changes in central nervous system, and reduces pain. Investigation hypothesis was that preoperative epidural clonidine is more efficient in blockade of systemic inflammatory stress response comparing to levobupivacaine. Patients were allocated to three groups, according to preoperative epidural use of clonidine, levobupivacaine or saline (control group). Before operation, 1 h after the beginning, 1 h, 6 h, 12 h and 24 h after the operation following parameters were analyzed: interleukine-6, C-reactive protein and leukocyte count. There were no significant differences between groups in age, gender, body mass index and operation time. In preoperative clonidine group, we found significant reduction in interleukine-6 levels throughout investigation time, compared to preoperative levobupivacaine group and control group. Also, C-reactive protein was significantly lower at the end of investigation, compared to other two groups. Leukocyte count was lower, and within the normal range in all investigation times only in preoperative clonidine group. We demonstrated significant difference that support importance of clonidine central effect on pain pathways and systemic inflammatory blockade.

Fetal macrosomia in pregnant women with gestational diabetes.

The aim of the study was to determine the frequency of fetal macrosomia in newborns from mothers with gestational diabetes mellitus (GDM) and healthy mothers, as well as determining the influence of fetal growth on pregnancy termination, on complications in pregnancy, during delivery and puerperium and on neonatal complications. In the study were included 351 pregnant women with GDM, as well as control group of 1502 healthy pregnant women. Newborns of mothers with GDM had significantly higher birth weight and length, ponderal index > 2.85 was more frequent, they were macrosomic and hypertrophic (disproportional and proportional), had smaller Apgar score and more frequent neonatal complications (p < 0.05). Fetal macrosomia and fetal hypertrophy alone or, particularly, connected with disproportional fetal growth, but disproportional hypotrophy as well, had significantly influence on greater frequency of delivery and puerperal complications, delivery completion with Cesarean section and neonatal complications in pregnant women with GDM.