The perinatal origins of major reproductive disorders in the adolescent: Research avenues.

The fetal endometrium becomes responsive to steroid hormones around the fourth month of pregnancy starting with an oestrogenic phase, which is followed late in pregnancy by a secretory phase. Based on post-mortem studies, the endometrium at birth is secretory in only one-third of neonates and proliferative in the remaining cases. Decidual or menstrual changes are rare in fetal endometrium despite high circulating steroid hormone levels, which drop rapidly after birth. Hence, acquisition of progesterone responsiveness appears to be dependent on endometrial maturation and relative immaturity may persist in a majority of girls until the menarche and early adolescence. Two major reproductive disorders have been linked with either advanced or delayed endometrial maturation. First, early-onset endometriosis may be caused by menstruation-like bleeding in the neonate, leading to tubal reflux and ectopic implantation of endometrial stem/progenitor cells. Second, persistence of partial progesterone resistance in adolescent girls may compromise deep placentation and account for the increased risk of major obstetrical syndromes, including preeclampsia, fetal growth retardation and preterm birth. The concept of neonatal origins of common reproductive disorders poses important research challenges but also subsumes potential new preventative strategies.

New Technique for Caesarean Section.

Caesarean section is one of the most common operations worldwide and more than 30 % of procedures in perinatal centres in Germany are caesarean sections. In the last few years the technique used for caesarean sections has been simplified, resulting in a lower postoperative morbidity. But persistent problems associated with all caesarean section techniques include high intraoperative loss of blood, the risk of injury to the child during uterotomy and postoperative wound dehiscence of the uterine scar. We present here a modification of the most common Misgav-Ladach method. The initial skin incision is done along the natural skin folds and is extended intraoperatively depending on the circumference of the baby's head. After blunt expansion of the uterine incision using an anatomical forceps, the distal uterine wall is pushed behind the baby's head. The baby's head is rotated into the occipito-anterior or posterior position and delivery occurs through the application of gentle pressure on the uterine fundus. Closure of the uterotomy is done using 2 continuous sutures, which are then knotted together resulting in a short double-layer closure. The two ends of the skin suture are left open to allow for natural drainage. Our experience at the University Gynaecological Hospitals in Novi Sad and Magdeburg has shown that this modification is associated with shorter operating times, minimal blood loss and shorter in-hospital stay of patients as well as high rates of patient satisfaction.

[A proposed protocol for obstetrical ultrasound examination]. / Predlog protokola za akuserski ultrazvucni pregled.

INTRODUCTION: Ultrasound has a number of valuable functions in obstetrics including dating, confirming viability, counting the number of fetuses and the exclusion of gross fetal anomalies. During two routine obstetric ultrasound scans, between 11 and 14 gestational weeks and around 20 weeks, the fetus should be carefully examined after which the existence of anomalies can be confirmed or, with a limited certainty that ultrasound enables, excluded. In order to obtain high standards of ultrasound screening, a uniformed protocol is needed, which would enable standardized examination. In this paper the Novi Sad University Department of Obstetrics and Gynaecology presents a new protocol for ultrasound examination which would ensure standardized ultrasound scanning and adequate record keeping. MATERIAL AND METHODS: The protocol is based on contemporary recommendations of the Royal College of Obstetricians and Gynaecologists of Great Britain, the Royal College of Radiologists of Great Britain, the American College of Obstetricians and Gynaecologists, as well as protocols used in routine ultrasound examinations of low-risk population (1,2,3,4,5,6). RESULTS: There are two protocols: one for scanning in the first and the other in the second/third trimester. All the findings are recorded in adequate forms. In the first trimester number, viability, gestational age and expected date of delivery are established (4,6). At the end of the first trimester an anomaly scan can be performed as well (8,9,10,11,12). It includes measuring of crown-rump length, nuchal translucency and fetal heart rate, and examination of placenta, skull, brain, spine, abdomen, stomach, bladder and upper and lower extremities. An adjusted risk of chromosomal abnormality is given, based on maternal age and nuchal translucency measurement. In the second and third trimester the usual fetal biometry is performed as well as a detailed scan of anatomy, which includes searching for ultrasound markers of chromosomal abnormality. At 23 weeks the transvaginal evaluation of cervical length is performed, in an attempt to screen for women at risk of preterm delivery. A new, adjusted risk of chromosomal risk can be given, based on maternal age, nuchal translucency measurement in the first trimester and presence/absence of ultrasound markers of chromosomal abnormality. DISCUSSION: Ultrasound in obstetrics has a major role. All scans in pregnancy must have clear aims, which in early pregnancy are (2): establishing fetal viability; establishing gestational age; identification of multiple pregnancies and their horionicity; exclusion of major fetal anomalies; psychological support and in second trimester are (4,13): (1) establishing normal ultrasound appearances of the fetus, which does not mean that the fetus is normal. The expression 'normal' should be avoided because of possible medico-legal implications. (2) identification of: anomalies incompatible with life; anomalies linked with high morbidity and long-term handicap; fetal conditions than that can be treated during intrauterine life; fetal conditions that will need postnatal tests and therapy. CONCLUSION: New protocol and forms will enable an easier systematic obstetric ultrasound examination.

[Folic acid in the prevention of neural tube defects]. / Folna kiselina u prevenciji defekta neuralne cevi.

INTRODUCTION: The term neural tube defects (NTD) stands for anencephaly, iniencephaly, cephalocoele and spina-bifida. The cause of these anomalies is failure of brain spinal cord to properly develop, together with their protective shield of skull and spine, around the 4th gestational week. The prevalence of NTD in continental Europe is 11.2 10,000 live births. THE LEVEL OF FOLATES IN SERUM AND NTD: The level of folates in serum can influence the risk of a child affected with NTD. Studies on women with previous pregnancies with NTD showed that supplementary intake of folic acid, with or without other vitamins, preconceptual period throughout the first trimester has a preventive effect on its recurrence. Inadequate intake of folic acid is also connected with preterm delivery, intrauterine growth retardation and placental abruption and infarction. FOLATES IN NUTRITION: It is not folic acid, but folates, from the vitamin B group, that can naturally be found in food. There are several groups of folates that differ in the quantity by which they can be absorbed from food. Folates are temperature and storage sensitive and cooking can cause a significant fall of their concentration in food. FOLIC ACID SUPPLEMENTATION: The mean daily intake of folates by food is 0.218 mg whereas a reference nutritive intake for a woman of reproductive age is 0.2 mg per day. The currently recommended daily dose for prevention of first NTD occurrence is 0.4 mg, so it is clear that a certain amount of folic acid has to be supplemented preconceptionally and during the first trimester. It can be done in two ways, by telling all women to take it before conceiving, or to fortify food with sufficiently high doses of folic acid in order to achieve adequate serum levels. Neither of the ways is ideal, for not all women would take the supplement, and by aggressively fortifying the food, we create a potential hazard to those that do not need it and may have some problems with the excess of it. The best solution would be a widespread campaign about the need for folic acid and the risks of NTD. CONCLUSION: Recommendations of The Expert Advisory Group on Folic Acid in prevention of neural tube defects has several aspects (1) reducing the risk of the first NTD occurrence by preconceptional vitamin supplementation of folic acid in the dose of 0.4 mg day, which would go on until the end of the 12th week (2) reducing the risk of NTD recurrence in offspring of men and women with spina-bifida or with obstetric history affected with NTD by preconceptional vitamin supplementation of folic acid in the dose of 4 mg daily during the first 12 weeks and (3) organizing educational programmes for medical staff as well as the whole population in order to popularize vitamin supplementation.

Induction of labor by endocervical application of prostaglandins and intravenous infusion of oxytocin in postterm pregnancy.

The study compares two contemporary modes of labor induction: intravenous application of Syntocinon and endocervical application of prostaglandins and examines their efficacy and safety. Ninety women were divided according to the degree of cervical maturation (shown by Bishop score) into two groups. In group I there were 60 women with unripe cervix (Bishop score < or = 5) and induction was performed by endocervical application of 0.5 mg Dinoprostone, and in group II there were 30 women with ripe cervix (Bishop score < or = 6) in which the induction was performed by intravenous application of Syntocinon (500 ml of 5% glycose with 10 iu of Syntocinon). After three hours the initially significantly different Bishop score values were equalized and it was possible to correlate the duration of the labor (Group I 545 min, Group II 338 min). The correlation of initial Bishop score values and the total duration of the labor was negative and high in both groups. All the neonates from both groups were in good condition and no serious complication was noted. Both methods of labor induction appear similarly effective and safe both for the fetus and the mother.

[Infertility and endometriosis]. / Infertilitet i endometrioza.

The goal of this study was to set the relation between infertility and endometriosis. It included 500 infertile female patients who underwent laparoscopy in order to find out the cause of infertility. The prevalence of endometriosis in these patients was 26%, that is significantly higher than in the control group which consisted of 200 randomly chosen fertile women in whom prevalence of endometriosis was 5%. Patients with endometriosis mainly belong to the group of 25-29 years of age with a median duration of infertility of 2-4 years. Endometriosis occurs three times more often in the group of patients with primary sterility than in patients with secondary sterility. Majority of patients (71.5%) are with minimal or mild endometriosis.

[Modern aspects in the diagnosis and treatment of gynecologic diseases in childhood and adolescence]. / Savremeni stavovi u dijagnostici i lecenju ginekoloskih oboljenja u decijem i adolescentnom uzrastu.

Gynecological problems in juvenile and adolescent age deserve a special attention. Disorders appearing at this age are not identical with those developing in adults. Diagnostics and therapy of gynecological diseases in juvenile and adolescent age are far more complicated than the same procedures with adult women, while instruments and examination protocols have to be adjusted to the age of patients. To maintain the purpose of preserving the generative function and sexuality of an adult woman early detection and treatment of gynecological diseases of juvenile age are essential. The paper focuses at the analysis of the most frequently appearing disorders in juvenile and adolescent age: vulvovaginitis, foreign parts in vagina, development anomalies, synechia vulvae and injuries. It is essential to recognize certain diseases in order to prevent possible consequences in older age. Following diseases appearing in adolescents have also been analyzed: menstruation disorders (with an emphasis on menstruation disorder influenced by body weight), sexually transmitted diseases, pregnancy detection and complications.

[Modern noninvasive methods for early detection of chromosome anomalies]. / Savremene neinvazivne metode za rano otkrivanje nekih hromozomskih anomalija.

Chromosome abnormalities may be a major cause of perinatal death and handicaps, and that is why the most common indication for invasive prenatal diagnosis is the risk or suspicion that there are certain cytogenetic abnormalities. In order to determine high-risk women for invasive diagnosis, it is necessary to establish noninvasive screening methods which would be performed in a major part of pregnant population. This article reviews contemporary noninvasive methods for early detecting of certain chromosome abnormalities such as ultrasound and biochemical markers. Combined application of these methods enables detection of more than 80% of fetuses with chromosome anomalies in the second-trimester pregnancies.

[Cesarean hysterectomy im modern obstetrical practice from 1968 to 1993]. / Histerektomija cezarea u savremenoj opstetrickoj praksi u periodu 1968-1993. godina.

A retrospective study of cesarean hysterectomies at the Department of Obstetrics and Gynecology in Novi Sad was conducted for the period 1968-1993. There were 129,127 deliveries, whereas cesarean section was performed in 10,485 (8.12%) cases. There were 55 cesarean hysterectomies (0.042%), while in 0.52% they were performed during cesarean section. Elective hysterectomy was performed in 7 (12.73%) cases because of neoplastic process and uterine myoma, while in 48 (87.27%) cases it was performed for heavy bleeding. Most often bleeding occurred due to complications of placenta previa, uteroplacental apoplexy, premature placental ablation, uterine rupture and atony. Total hysterectomy was performed in 30 (54.54%) cases and subtotal hysterectomy in 25 (45.45%) cases. Bilateral adnexectomy was performed in 3 (5.45%) cases. Urinary bladder injury occurred in 4 (7.27%) patients, wound infection in 11 (20.00%) patients, urinary infection in 3 (5.45%) and pelvic peritonitis in 1 (1.82%) patient. One maternal death (1.82%) occurred due to DIC (disseminated intravascular coagulation). Out of 57 delivered newborns 20 (35.10%) died in the perinatal period. There were 13 stillbirths (22.80%), whereas 7 newborns (12.30%) died in the early neonatal period due to prematurity and RDS (respiratory distress syndrome).

[Immunologic characteristics of peritoneal fluid in endometriosis]. / Imunoloske karakteristike peritonealne tecnosti kod endometrioze.

Increased volume of peritoneal fluid is found more frequently in patients with endometriosis (51%) than in infertile patients without endometriosis (13%). Immunologic analysis of the peritoneal fluid shows that in patients with endometriosis the level of immunoglobulin G (IgG) increases. We analyzed 34 samples of peritoneal fluid from patients with and 13 from patients without endometriosis. The mean value of IgG in the group of patients with endometriosis was 7.73g/L and 3.94g/L in the control group. This difference is statistically significant, but there is no statistically significant difference in regard to immunoglobulin A (IgA), while it has been significant for immunoglobulin M (IgM) only in the third stage of the disease. In certain stages of illness there are no statistically significant differences in values of all three immunoglobulin types. A golden standard of immunoglobulin G in peritoneal fluid is 5g/L and in regard to this level we calculated the following: sensitivity, specificity, prognostic value and accuracy of the test. Sensitivity and positive prognostic value reached 85.3%. On the basis of these findings it can be concluded that if no endometriosis can be seen during laparascopy while the volume of peritoneal fluid is increased, immunologic analysis should be performed. If IgG values are 5g/L or higher, the patient should be treated as a patient with possible "precursor endometriosis".

[Pelvic inflammatory disease and the use of intrauterine contraceptive devices]. / Pelvicna inflamaciona bolest kod primene intrauterinih kontraceptivnih ulozaka.

Pelvic inflammatory disease includes a group of different diseases such as: endometritis, salpingitis, oophoritis and peritonitis. The risk of pelvic inflammatory disease in intrauterine contraceptive devices--users is 7-9 times higher than in the general population, whereas the incidence of occurrence of these diseases in this certain group is 2-5%. During the period 1989-1993, 155 intrauterine contraceptive users with pelvic inflammatory disease, were treated at the Clinic, which makes 25% of all hospitalized female patients with pelvic inflammatory disease. Serious cases have been established in regard to the period 10 years ago. In order to prevent the occurrence of pelvic inflammatory disease in users of intrauterine contraceptive devices, health education is necessary to motivate regular controls and check-ups, preventive application of antiseptic vaginal tablets and detection of signs of the disease.

[Use of suture materials in gynecologic surgery]. / Primena savnog materijala u ginekoloskoj hirurgiji.

This paper presents evolutionary development of suture materials in surgery from the "period of renaissance" to these days. Ideal suture materials in surgery should fulfil characteristic demands such as the four following: safety of knots, tension force, tissue reactions and wound safety. The table presents absorptive and nonabsorptive suture materials especially taking into consideration the application of the materials in contaminated-inflamed tissues. Recommendations in regard to choice of surgical suture materials are given considering gynecologic surgery.

[Modern approach to classification of precancerous conditions and vulvar dystrophy]. / Savremeni pristup u klasifikaciji prekanceroza i distrofija vulve.

Precancerous conditions of vulva are diseases which can exceed into carcinomas and are called preblastomatoses. These are all sorts of various diseases: intraepithelial vulvar neoplasias, Paget's disease, precancerous circumscript melanosis, malignant melanoma of the first Clark level, verrucous type of leukoplakia, vulvar dystrophy with atypia, giant Buschke-Lowenstein's condyloma and chronic skin damages. Vulvar dystrophy belongs to medical terminology since 1966 and includes a group of diseases known as leukoplakia and kraurosis, primary vulvar atrophy and hyperplastic vulvitis. According to classification from 1987 vulvar dystrophies are divided into: squamocellular hyperplasia, lichen sclerosus and other dermatoses. The term vulvar leukoplakia is not a special disease, but is used for a whole group of different lesions of white color due to leukoderma, vitiligo, chronic infections, benign tumors, dystrophies and even invasive carcinomas.

[Actinomycosis of the minor pelvis associated with prolonged use of intrauterine contraceptive devices (IUD)]. / Aktinomikoza male karlice udruzena sa dugotrajnom primenom intrauterinog kontraceptivnog uloska (IUD).

Pelvic actinomycosis is a rare disorder caused by Gram-positive anaerobic bacteria Actinomyces Israeli, and it is commonly associated with the prolonged use of IUD. The authors present two cases of pelvic actinomycosis in patients who used IUD for prolonged periods of time (eight and fourteen years). The diagnostic procedure in both cases lasted long and the definite diagnosis was made only after the pathohistological examination of the material taken during the surgical treatment. Actinomyces Israeli should be considered as one of the causes of the diagnosed pelvic inflammation especially when it is associated with the prolonged use of IUD.

[Diagnostic significance of preoperative determination of CA-125 serum levels in the differentiation of malignant and benign pelvic masses]. / Dijagnosticki znacaj preoperativnog odredivanja koncentracije CA-125 u serumu u diferencijaciji malignhin i benignih karlicnih tumefakcija.

Preoperative estimation of serum C-125 tumour marker was performed in 45 patients with adnexal malignancies, 50 patients with benign pelvic masses and in 30 healthy women who underwent plastic surgery for disturbed statics of genital organs. Elevated serum CA-125 values (above 65 U/ml) were observed in 38 (84.5%) patients with ovarian malignancies (chi = 355.93, SD +/- 251.86) and in 7 (14%) patients with palpable benign pelvic masses (chi = 48.09, SD +/- 77.08). Preoperatively evaluated serum CA-125 values were not evident in the control group (chi = 7.20, SD +/- 6.98). There were statistically significant differences (T = 8.13, p < 0.05) between preoperative mean serum CA-125 values in the patients with malignant and benign pelvic masses. Also, there was statistically significant difference between the control group, the group with malignancies (T = 7.48, p < 0.05) and the group with benign pelvic masses (T = 2.86, p < 0.05). Preoperative assessment of the serum CA-125 values proved to be significant but not absolutely reliable laboratory-diagnostic parameter in differentiation of malignant and benign pelvic masses in the female.

[Evaluation of short-term exposure to a polyacrylonitrile cervical dilator in preabortion preparation of the uterine cervix in adolescent girls]. / Evaluacija kratkotrajne ekspozicije poliakrilonitrilskih cervikalnih dilatatora u preabortusnoj pripremi grlica materice adolescenata.

Authors investigated possibilities of application of polyacryl-nitrile cervical dilators PCD-Dilapan in preabortion preparation of the cervix during the first trimester of pregnancy in 39 adolescent patients. Control of the achieved degree of cervical dilatation was performed by largest No Hegar dilator which did not show resistance during insertion. The control group comprised 35 adolescent patients in whom cervical dilatation was performed only by Hegar dilators till optimal dilatation for vacuum aspiration was achieved. Mean cervical dilatation in the investigated group was means = 8.85 mm (SD +/- 0.85) and in the control group means = 8.55 mm (SD +/- 0.78) with no statistically significant difference (T = 0.024, p greater than 0.05). "Analogous visual scale" was used for pain estimation during cervical dilatation. In the investigated group means = 2.01 (SD +/- 1.83) of pain degrees while means = 6.71 (SD +/- 1.89) in the control group. Side effects during cervical dilatation were noted in 15.38% of patients in the investigated group and in 51.41% of patients in the control group which difference was not statistically significant (chi 2 = 5.59, p greater than 0.05).

[Conditions and indications for urodynamic examinations]. / Uslovi i indikacije za urodinamska ispitivanja.

Urodynamic investigations (UDI) present a new diagnostic method for the research of the physiology, pathophysiology, biomechanics and hydrodynamics of the urine flow. The purpose of UDI is to establish the function of the lower part of the urinary tract, most frequently in the presence of urinary incontinence. They are used in gynecology, urology, neurology, pediatrics, rehabilitation, geriatrics and general surgery. There are absolute and relative indications for UDI. Adequate preparations of the patient are necessary prior to UDI. Exact diagnostics of the impaired function of the lower part of the urinary tract can be maintained only by a complete performance of the UDI objectivity tests. A correct diagnosis will enable adequate therapy.