[PROLONGED RETAINED PLACENTA ACCRETA IN THE UTERUS AFTER VAGINAL DELIVERY (A CASE REPORT AND REVIEW OF LITERATURE)].

A case of prolonged retention in the uterus of placenta accreta after vaginal delivery is reported in the paper. The patient was 20 years old G3, P0 with two pregnancy terminations on request. She was admitted to the obstetric department of a regional hospital one day after the EDD with irregular contractions and non reassuring CTG. A few hours later intrauterine fetal demise occurred. Spontaneous labor commenced and a stillborn growth retarded fetus was delivered. Methergin was administered during the third stage of labor, but the placenta was not separated even after repeated Crede maneuvers, the last one under anesthesia. Since cervical spasm was present, the attempts for manual or instrumental separation of the placenta were unsuccessful. There was no genital bleeding, so further conservative approach was followed including continuous IV infusion of uterotonics, combined antibiotic therapy, close observation of the vital signs and the laboratory indicators. Three days after delivery the patient was transferred to a University Hospital because of subfebrile temperature. Her general condition on admission, although subfebrile, was good, there was no genital bleeding, the cervix was closed. The subfebrile temperatrure persisted despite antibiotic treatment; CRP was elevated (51,9 mg/l.). Because of suspicion for endomyometritis, on day 8th after delivery instrumental extraction of the placenta was undertaken with preparedness for hysterectomy in case of need. Although the procedure was difficult, with the placenta being extracted in parts, bleeding was scarce. The post operative period was uneventful and the patient was discharged from hospital five days after the intervention. A review of literature on the obstetric management of cases with retained placenta accreta after vaginal delivery is presented. The existing therapeutic options are discussed including their advantages and complications.

[CRIB II score and method of delivery for very low and extremely low birth weight infants].

UNLABELLED: The purpose of this study is to determine the influence of method of delivery on CRIB II score in preterm infants born in vertex presentation < or = 32 weeks of gestation. MATERIAL AND METHODS: Prospective study over five years period (2006-2010) that includes 162 cases. 115 (71%) of patients are delivered vaginally and 47 (29%) with cesarean section. CRIB II score is used as a tool for measuring the risk of neonatal dead and severe morbidity in neonatal period. It's predictive value is based on the birth weight, gestation weeks, gender, the lowest values of BE (base excess) in the first hour of life and the temperature at acceptance in neonatal intensive care unit. There is a reciprocal dependence between CRIB II, duration of pregnancy and birth weight. This requires a comparison of vaginal birth and Cesarean section in the following subgroups: 25-26 weeks, 27-28 weeks, 29-30 weeks and 31-32 weeks and weight 500-750 g., 751-900 g., 901-1000 g., 1001-1250 g. and 1251-1500 g. RESULTS: Mean score values for vaginal births are 14.08 p. (points) at 25-26 weeks, 10.54 p. at 27-28 weeks, 6.90 p. at 29-30 weeks and 5 p. at 31-32 weeks. In the same periods of pregnancy mean CRIB II in Cesarean section deliveries are 13, 6 p., 10, 58 p., 7, 85 p. and 5 p. Significant statistical difference is not found between groups. Results remained almost unchanged after adjusting for birth weight in vaginal and cesarean births. CONCLUSION: The risk of poor perinatal outcome assessed by CRIB II is independent of the method of delivery but strongly influenced by the duration of pregnancy and birth weight.

[A case of cervical myoma and pregnancy].

We are presenting a case of women in 31 gestational week of her pregnancy with prematurely ruptured membranes and 10.5 cm myoma in the vagina. The cervix was elevated with well-defined external orifice, dilated to 10.5 cm. C-section with myomectomy was performed. The myoma had penetrated in the vagina with a lot of adhesions to the rectum and cavum Douglais. The vaginal vault and the posterior cervical wall were restored with single sutures. Smooth postoperative period.

[Bishop score and outcome of labor in pregnancy < or = 32 weeks of gestation].

UNLABELLED: The purpose of this study was to find correlation between early changes in Bishop score and the subsequent method of delivery < or = 32 g.w. MATERIAL AND METHODS: A prospective study for five years period (2006 - 2010) included 235 patients who met the following criteria: 1) single birth; 2) gestational period < or = 32 weeks; 3) appropriate for gestational age; 4) livebirths. RESULTS: At admission to hospital we found a significant difference in mean Bishop score between those delivered vaginally (6.64 p.) and by Cesarean section (2.85 p.) and minor changes in Bishop during the time from hospitalization to decision point for CS (3.6 p.). In cases with score < or = 5 p. our results showed threefold increased incidence of abdominal delivery (53.1% vs. 17.1%). CONCLUSION: Changes in Bishop score at admission to hospital in cases of irreversible preterm birth due to spontaneous uterine activity or PROM determine the method of delivery < or = 32 weeks.

[Efficiency of Cikatridina spray for healing of episiotomy and perineal ruptures].

UNLABELLED: Episiotomy is the most common surgical intervention during childbirth. Cikatridina spray allows treatment of this primary contaminated surgical wound and assist its primary healing. The aim of this study is to determine the effectiveness of aid healing of episiotomy, and spontaneous perineal ruptures after normal and operative vaginal delivery. MATERIAL AND METHODS: The study included 90 women after spontaneous or operative vaginal delivery with episiotomy or a spontaneous perineal rupture treated with Cikatridina spray. Control group of 90 women was used to compare the efficency. The status of the wound was determined on the first, third, fifth and 30th day after birth, according to presence of the following symptoms: redness, swelling, pain, exudation, epithelization, open wound. RESULTS: Symptoms of redness, swelling and pain in the group treated with Cikatridina spray after normal birth resolved on the third postpartum day in 100% of cases. Same symptoms after operative vaginal birth persist in average 9% of women and resolved on the 5th day When comparing treated patients with Cikatridina spray with perineal ruptures and the control group in 100% were reported no symptoms in the study group compared with the control group where the redness, swelling persist in 20% and 85.7% epithelization is showing at 5 postpartum day. There was one open episiotomy of a patient from a control group after operative vaginal birth healed in 26 days. CONCLUSIONS: Cikatridina spray effectively eliminates symptoms of redness, swelling and pain regardless of perineal trauma and the method of delivery. There is an earlier epithelization after using the Cikatridina spray. Open and infected perineal wounds are treated with conventional medicines.

[Frequency and characteristics for forceps delivery].

AIM: To establish the incidence of vaginal operative deliveries by extraction of the fetus with forceps and the degree of prematurity of newborns in which it is applied, to specify the type of forceps which is imposed. MATERIAL AND METHODS: The study included 672 births, completed by extraction of the fetus with forceps in the period 1994-2008 year in University hospital "Maichin dom" Sofia. The total number of births was 47,130, of which 32,924 have become per vias naturalis. Age of birth was from 13 to 42 years. The study was done prospectively and retrospectively. RESULTS: The incidence of forceps extraction of the total number of births for the period is 1.43%, as seen following the trend - in the first years of the period 1994 - 1995 is more than 2% of total births, in the period 1996 to 2003 years and then fluctuated between 1 and 2%, and after 2004 has decreased below 1%. There could be noticed slight and gradual reduction in the incidence of operative vaginal delivery by forceps. The general incidence of forceps extraction compared to vaginal births was 2.04% for the entire period, at the beginning is 3.5% and then fell between 2.5 and 2% for the period 1995 to 2003 years, then in 2004 was between 1 and 2%. In 94.8% of cases forceps was applied to term fetuses and 5.2% of cases in preterm fetuses (respectively 3.78% in premature fetuses 1-st degree, 1.10 percent premature fetuses II-nd degree and 0.31% in premature fetuses III-grade). In 74.65% of the cases was outlet forceps and 25.35% was low forceps. CONCLUSIONS: Forceps remains an irreplaceable tool for operative vaginal birth, but there is a tendency to reduce its use. In preterm fetuses forceps is the only method for vaginal operative delivery. Today only outlet and low forceps have their role in modern obstetrics, but there is a trend to reduce the incidence of the rotational forceps in comparison to increase of the use of outlet forceps.

[Some aspects of maternal mortality in Bulgaria].

The author discusses the world and bulgarian maternal mortality rates and suggests the creation of obligatory diagnostical and therapeutical guidelines in urgent obstetrical cases.

[Neonatal dead and method of delivery < or = 32 weeks of gestation].

UNLABELLED: The purpose of this study is to determine the dependence of neonatal dead by method of delivery at prematurity. MATERIAL AND METHODS: Prospective study on 238 single births from 25-32 g.w. According to the method of delivery and fetal presentation newborns are divided into the following groups: vertex presentation - vaginal birth (PN) and Cesarean section (SC) and breech presentation - PN and SC. RESULTS: For the period, in the first 28 days after birth died 42 (17,7%) infants and 196 (82,3%) were survivors. Depending on the mode of birth statistically significant difference in the incidence of death after birth is not found in vertex presenting newborns (25% CS vs. 16,5% PN; p > 0.05). Unlike in breech presenting fetuses, vaginal birth < or = 32 weeks increases more than twofold neonatal dead compared with CS (20% vs. 7,7%; p < 0.05). Unfavourable outcome in CS is strongly associated with fetal presentation - three times higher neonatal dead in vertex presenting group (25% vs. 7, 7%; p < 0.05), as a result of higher incidence of absolute fetal indications (68,1% vs. 43,2%; p< 0.05). CONCLUSION: The way of birth doesn't affect the frequency of dead within the first 28 days of life in vertex presenting fetuses. Vaginal breech delivery is a risk factor for unfavourable neonatal outcome < or = 32 w.g. Survival in CS is dependent on both fetal presentation and obstetric complications, requiring operation.

[Indications for vaginal delivery with forceps application].

UNLABELLED: The aim of the study was to establish indications for operative vaginal delivery by extraction of the fetus with forceps in modern obstetrics. MATERIAL AND METHODS: This is a retro- and prospective study which includes 672 forceps deliveries in the period of 1994-2008 in Maternity hospital Sofia. Simpson and Kielland were used for extractions subject to appropriate indications and conditions, regardless of the gestational week of pregnancy. RESULTS: The most frequent indication for forceps application is fetal asphyxia (78.1%) and considering the frequency for 15 years it is the permanent, leading indication for forceps in modern obstetrics. Arrest of the head in the same plane of the pelvis was the indication in 23.6% of the cases it varies and is rarely primary through the 15 year period. Ineffective uterine contractions and/or pushes (16.7%) tends to decrease its frequency. Avoiding maternal efforts in the second stage of labor (8.5%) and in 50% of the cases was indicated for women with cardiovascular diseases. Malpositions (7.7%) increases through the years probably secondary to epidural analgesia. Indication preeclampsia-eclampsia is described in 1.3% of cases, followed by genital bleeding by 1.9% and prolapse of the umbilical cord by 0.6% and they are more incidentally reasons for application of forceps. CONCLUSION: Asphyxia of the fetus is the most common and a leading indication for extraction of the fetus with forceps. Ineffective uterine contractions and the arrest of the head in the same plane of the pelvis are consistent in their occurrence and lead to prolonged labor. In certain critical conditions (genital bleeding, prolapse of the umbilical cord and eclampsia) extraction of the fetus with forceps remains the only way for fast vaginal delivery.

[Frequency of multiple pregnancy].

OBJECTIVES: The aim of this research was to find out the frequency and tendency of multiple pregnancy. Study design. There are used retrospective and prospective comparative analysis. The study includes 51162 births, 960 twins, 39 triplets and 1 quadruplets. RESULTS: The number of multiple pregnancy in 1994 was 44, but in 2009 it was 152. The frequency of twins increased from 1.18% in the beginning of the observed period to 3.62% in the end of the period. The frequency of triplets chanced from 0.06% to 0.34%. We determined that the number of twins increased 3 times and the number of triplets - 6 times. In the beginning of the researched period in 2005, the frequency of twin pregnancy shows a tendency of smooth increase, while form 2006 there is a significant and rapid increase. The frequency of the triplet's births shows relative stability from 1996 till 2006, while from 2007 till now there is a progressive increase in it too. CONCLUSIONS: There is a significant increase in the frequency of the multiple preganancies, observed in twins as well as in triplets. There is a stable tendency of increasing, which has the following characteristics smooth growth in the beginning of the period and rapid expand in the last years. The problem of the increasing frequency of the multiple pregnancies and the following up complications must be the aim of our future research and discussion.

[Spontaneous pneumothorax during pregnancy--a case report].

Authors present a case of spontaneous pneumothorax, which developed twice during the pregnancy of a lady, who delivered at term by a Cesarian section. Spontaneous pneumothorax is an extremely rare complication in pregnancy. The etiology of this condition is variable and previous broncho-pulmonary pathology is often found. Spontaneous pneumothorax may occur in any time during the pregnancy period. Early detection and prompt diagnosis of this condition are important for the prevention of some severe complications. The diagnostic and therapeutic methods used in pregnancy do not differ essentially to those used in non-pregnant patients. Delivery in such women can be performed per viasnaturales, with effortless bearing period, as well as per a Cesarian section, according to the severity and current condition of this complication.

[Fracture of clavicle in newborns, an attempt to make prognostic factors].

UNLABELLED: The most common bone fracture of the newborn is that of the clavicle - frequency 0.2-3.5% of all births, according to various literature sources. The most common cause of this complication perinatally determining the weight of the newborn and the skills of those who manage second stage of labour Purpose of the study was the establishment of prognostic factors for fracture of the clavicle regardless of the way of delivery. MATERIAL AND METHODS: The study was retrospective for the period January 2005 to June 2010 and includes 38 infants with fracture of the clavicle in spontaneous and operative vaginal deliveries, as well as caesarean sections. There were examined the following factors: age, parity and maternal weight, fetal weigh and length duration of pregnancy, experience of managing labour. RESULTS: The incidence of fracture of the clavicle during the study was 0.26%, calculated to the total number of births. Eight fractures are of newborn delivered by caesarean section, 6 by vacuum extractor and 24 by normal vaginal deliveries with episiotomy mostly. The average weight of infants with fractures was 3767 gr 3 fractures are accompanied by brachial plexus paresis, and 2 were complicated with shoulder dystocia. CONCLUSIONS: It was not found statistically significant prognostic value of most of the indicators studied. Fracture of the clavicle most often dependent on the weight of the newborn and the technique of managing labour without the consequence of shoulder dystocia.

[Isolated right aortic arch with diverticulum of Kommerell--prenatal diagnosis with spatio-temporal image correlation (STIC)].

Isolated right aortic arch is a rare congenital cardiac malformation which is often diagnosed only after birth. We present a case of isolated right aortic arch with a vascular ring and diverticulum of Kommerell diagnosed prenatally at 21 weeks of gestation (w.g.) with three-dimensional ultrasound and spatio-temporal image correlation (STIC). The clinical implications, prenatal diagnosis, differential diagnosis and perinatal management in such cases are discussed.

[Caesarean section by vertical incision of lower uterine segment].

OBJECTIVES: The aim of the study is to analyze the use of vertical incision of the lower uterine segment when performing Caesarean section (CS). MATERIAL AND METHODS: The study includes 89 pregnant women who delivered by CS. The main group includes 40 cases with vertical incision in lower uterine segment (preliminary intention, but final decision made during surgery) and controls--49 cases with transversal incision of lower uterus segment with difficulties/complications of fetus extraction (30 with uterine lacerations and 19 with T-form incision). The mean gestational age in the main group is 32 g.w. (range 26-39) vs. 31 in control group (27-39). RESULTS. Vertical incision of the uterus is performed in 57.5% due to prematurity and lack of enough space for transversal incision (lower uterine segment not yet formed), in 25 % the cause is situs transverses of the foetus and the rest of the cases are related with technical difficulties in isthmicotransversal approach (myoma praevia, anomalies of the uterus, adhesions of the omentum). C.S. is performed for mean 66 min. in the main group vs. 74 min. with controls (p < 0.05). Time to extraction of the foetus is less than a minute in main group vs more than a minute with controls. No lacerations are found with vertical incision of uterus. Blood loss in main group is 664 ml, vs. 884 ml in control group (p < 0.05). Mean values of pH from umbilical artery of the newborn is 7.257 in main group vs. 7.19 in controls (p < 0.05), resp. Apgar scores atb 5-th min. is 7 vs 6. CONCLUSIONS. Vertical incision of lower uterine segment before the formation of the latter, with situs transversus of the foetus and difficult approach renders the option for less lacerations intra operationem, less birth trauma with better final outcome for the newborn.

[Scar uterine rupture after 6 pregnancies with cerclage].

The scar uterine rupture is the most common reason for uterine rupture, because of the increased frequency of the myomectomia, cesarean sections and others. We present a case of a scar rupture in multiparous woman with seventh pregnancy, six of them with cerclage. The numerous cerclages has caused changes (lacerations) in the cervix, which made necessary each next cerclage to be placed higher and probably in the uterine isthmus. In our case the rupture started in the lower uterine segment and is combined with rupture of the bladder, which is the most common complication of the uterine rupture. We conclude that in cases with several cerclages the status of the uterus and the cervix should be evaluated very carefully and the way of delivery should be discussed.

[Application of sumamed in treatment of bacterial vaginal infections during pregnancy].

OBJECTIVE: To study the efficacy of Sumamed in cases of endogenous bacterial vaginal infections during third trimester of pregnancy. MATERIALS AND METHODS: 34 women in last trimester of pregnancy with Streptococcus group B, Streptococcus group A, alpha hemolytic Streptococci, S. aureus infections and intermediate state of vaginal ecosystem (Nugent score 4-6) were treated with Sumamed (Azithromycin, 500 mg. p.o. for 3 days). Patients were separated in two groups. First group included 19 women with symptomatic and microbiologically proven recurrent vaginal infection during last 6 months. Second group included 15 symptom free pregnant women, in whom, pathogenic bacteria were found on vaginal swab and culture. RESULTS AND DISCUSSION: Culture revealed 2 cases of Streptococcus group A infection in the second study group. Streptococcus group B was isolated in 19 patients--11 group 1 and 8--group 2. S. aureus was found in 6 patients from group 1 and 3 patients from group 2. Alpha hemolytic streptococci were cultured in 4 cases--2 from group 1 and 2 from group 2. Isolated microorganisms showed in vitro sensibility toward Sumamed. After treatment completion, control swab and culture was performed in 26 cases (14 group 1 and 12 group 2 patients). In group 1 in 12 (85,7%) patients no pathological microorganisms were cultured, Nugent scores were between 0-3 and no subjective symptoms were reported. 2 (14,3%) patients had Candida infection. In the second group 10 patients (83,5%) had normal vaginal microbiology, 2(16,5%) remained with intermediate vaginal microflora state. No newborn infections and cases of endometritis were found in both study groups. Sumamed is an efficacious treatment in cases of streptococcal and staphylococcal vaginal infections during pregnancy. Application of Sumamed results in alleviation of clinical symptoms and in sanitation of birth canal.

[Fetal achondroplasia--antenatal diagnosis of two cases].

Achondroplasia is a rare autosomal dominant skeletal dysplasia associated with rhizomelic micromelia and facial dysmorphism. Prenatal diagnosis of achondroplasia is possible after 20 weeks of gestation when its main characteristic features can be easily recognized on ultrasound. We present two cases of achondroplasia diagnosed in the second trimester of pregnancy.

[Puerperal uterine involution according to the method of delivery].

UNLABELLED: The aim of the study is to determine and estimate the absolute values of the distance between the symphysis pubis and the uterine fundus (S-FD) and the rate of uterine involution according to the method of delivery. MATERIAL: 150 women included in this prospective study are divided into 3 groups of 50 women with vaginal delivery, caesarean section and re-caesarean section. The absolute values of the distance S-FD and the rate of uterine involution were determined in cm and estimated according to their parity and the gestational age. The measurement of the S-FD was daily performed from the second day till the 5th day for the vaginal deliveries and till the 7th day for the caesarean sections. RESULTS: The uterine involution in primiparous and premature vaginal deliveries starts from lower values of the S-FD than in the multiparous and in cases of term delivery. The rate of uterine involution in primiparous increases gradually in the earliest day after delivery (from 0.95 to 1.6 cm per day), while in multiparous this increasing starts after the 4th day. When caesarean section is performed and in the cases of preterm delivery the rates of uterine involution are delayed and uneven. CONCLUSIONS: in cases of vaginal delivery the availability of prematurity and macrosomia of the fetus delays the rates of the uterine involution. The uterine involution after cesarean section is slower and unsteady, which is more conscious in re-sections.

[Assessment of Bishop's pelvic score in induction of labor prognosis].

Aim of the present mixed prospective and retrospective study is to determine the prognostic significance of the 5 parameters of the pelvic score of Bishop for the continuity and the final outlet of induction of labor. Based on the given results the authors conclude that the dilatation of the cervix is a good prognostic factor for the nulliparous and bad prognostic factor for multiparous. The effacement of the cervix is significant for the outlet of the induction regardless of parity. The level of the presenting part is a valuable criterion for the nulliparous when the pelvic is well assessed but for the multiparous it has no prognostic value. The firmness of the cervix has a bad prognostic value regardless of parity. The position of the is a good prognostic factor for the outlet of the induction but has no value prognosis of the continuity of the induction.

[Prognostic significance of Bishop's pelvic score for the continuity and the final outlet of induction of labor].

Aim of the present mixed prospective and retrospective study is to determine the prognostic significance of the pelvic score of Bishop for the continuity and the final outlet of induction of labor and to determine the optimal score in the beginning of the induction related with a successful outlet. Based on the given results the authors conclude that the pelvic score of Bishop has a good prognostic value for the continuity and the final outlet of induction of labor with a various values of the separate parameters. Pelvic score > or = 5 is related with a shorter and more successful inductions of labor.