Summaries of the “Vasile Dobrovici” CONFERENCE and of the National Congress of Urogynecology 26-28 November 2020

summaries of the “Vasile Dobrovici” CONFERENCE,

26-28 November 2020

 

 

 

Antimüllerian hormone – biochemical screening marker in reproductive endocrinology

 

Dragoş Albu¹, Alice Albu²

1. Department of Reproductive Medicine, Medlife Medical Center; “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

2. Department of Endocrinology, “Elias” University Emergency Hospital; “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Antimüllerian hormone (AMH) is a biochemical screening marker of ovarian reserve and is a good predictor of ovarian response at ovarian stimulation in in vitro fertilisation (IVF). However it is a poor predictor of clinical pregnancies and births. Methodology. The aim of the study was to analyze the relationship between antimüllerian hormone serum level and the in vitro fertilisation. We performed a retrospective study which included 1073 patients (mean age: 34.68±4.28 years old; mean body mass index: 22.7±15.65 kg/m²) who performed IVF between January 2013 and December 2016. Results. We found that AMH serum level was age-independent positively related with oocytes (beta=0.329, p<0.0001) and zygotes number (beta=0.248, p<0.0001) and negatively correlated with the fertilization rate (beta=-0.108, p=0.001). In the multivariate regression, after adjustment for confounders, only oocytes number, but not AMH serum level, was associated with zygotes number (beta=0.814, p<0.0001) and fertilization rate (beta=-0.133, p=0.001). Conclusions. Our study demonstrated that AMH has an age-independent association with the number of oocytes and zygotes, in spite of a negative impact on fertilization rate. We also found a bimodal relationship between AMH and pregnancy rates, which were positively associated in patients with AMH below 5 ng/mL, although higher AMH values seem to have a negative impact on pregnancy chances.

Keywords: AMH, IVF, ovarian reserve

 

 

 

 

Bone mass screening in anorexia nervosa

 

Simona Elena Albu^1,2, Mara Cârşote^3,4, Ana Valea^5,6, Cristina Vasiliu^3,4

1. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

2. Department of Obstetrics and Gynecology, Bucharest University Emergency Hospital, Romania

3. Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

4. Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania

5. Department of Endocrinology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

6. Department of Endocrinology, County Emergency Clinical Hospital, Cluj-Napoca, Romania

 

Introduction.Anorexia nervosa is a complex disease which includes psychiatric aspects, secondary amenorrhoea, nutritional damage etc. The condition has an alarming increasing incidence due to social pressure, including through social media. We aimed to focus on bone status in this disorder. Materials and method. This a general review. Results. Fat tissue damage due to weight loss decreases bone formation. Low estrogens decreases bone mineral density. However, estrogens replacement does not entirely restores bone mineral density. Also, negative contributors to skeleton are high cortisol values, anomalies of leptin, of bone turnover markers, chronic high oxidative status and inflamation, as well as dysregulation of gut microbiota. Moreover, puberty goes with suboptimal peak bone mass. Weight correction may be accompanied by catch-up growth, but not with a complete recovery of bone mineral density. Approximately 90% of subjects are found with low bone mineral density with more than 1 standard deviation below the values for age-matched healthy women. Conclusions. The damage of bone status in young females with anorexia nervosa causes low bone mineral density, reduced bone turnover markers, low calcium and vitamin D, impaired peak bone mass, and an overall higher fracture risk.

Keywords: bone mass, anorexia nervosa, fracture

 

 

 

Models of screening programs for cervical cancer – pathologists’ and gynecologists’ perspective

 

Raluca Anca Bălan¹, V.R. Gheorghiță²

1. Department of Morphofunctional Sciences I, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi; “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

2. Clinique de Champagne, Département d’Obstétrique et de Gynécologie, Troyes, France

 

Introduction. Regular screening tests, including human papillomavirus (HPV) genotyping and cervical cytology tests, used separately or combined, lead to the early detection of precancerous lesions and cancer of uterine cervix. The aim of this presentation is to compare the screening programs for cervical cancer of three important national cancer centers and to update the pathologists and gynecologists with their recommendations, thus creating a framework for discussions regarding the challenges in this national health field, for each of these two specialties. Materials and method. We performed the assessment of cervical cancer screening programs of the American Cancer Society, Public Health England, and of the French public health authorities based on medical literature review and internet search. Results. The guidelines of screening programs vary between countries, the recommendations for cervical cancer screening presenting similarities as well as differences in testing strategies, such as age of initiation, screening interval and the type of the test used (cervical cytology test or/and HPV genotyping). Conclusions. An independent multidisciplinary panel of experts should develop national guidelines for cervical cancer screening, considering the social and economic context of each country. Following the comparative evaluation of international screening guidelines, practical suggestions for the Romanian national program for the early active detection of cervical cancer may arise.

Keywords: cervical cancer, screening, HPV testing, precancerous cervical lesions, cervical cytology

 

 

 

Antenatal specialized surveillance improves maternal fetal outcome in twin pregnancy

 

Gabriela Caracostea¹, Dan Ona², Daniel Mureşan¹

1. First Department of Obstetrics-Gynecology, “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

2. First Department of Obstetrics-Gynecology, County Emergency Clinical Hospital, Cluj-Napoca, Romania

 

During the last years, an important increase of multiple pregnancies incidence was noticed mostly as a direct consequence of assisted reproductive therapies. Twin pregnancies have a high maternal fetal risk, being responsible for almost 10% of perinatal morbidity and mortality. The obstetric management is based on reliable methods that could identify these risks. Therefore, one of the most important aspects is an earlier diagnosis of chorionicity by ultrasound examination. On the other hand, sonography offers valuable information regarding the correct gestational age, zygosity and even the presence of fetal complications. The prenatal diagnosis of chromosomal anomalies is based on ultrasonography, biochemical tests and even on noninvasive test or amniocentesis. A careful follow-up identifies fetal complications in advance, allowing an appropriate decision. Nowdays we consider that, along with fetal risk, maternal complications such as preeclampsia, premature detachement of normally inserted placenta, anaemia, respiratory or metabolic anomalies must be also identified and treated. The optimal management of a twin pregnancy must take into account the fetal positions, the amnionicity, the gestational age at birth and the experience of the medical team. All these aspects will determine a good pregnancy outcome, regardless the delivery route. In conclusion, we consider that following and completing a twin pregnancy through the act of birth impose conditions of medical endowment, experience and professionalism of the whole team.

Keywords: twin pregnancy, maternofetal distress, chorionicity

 

 

 

VBAC – a change of obstetrical paradigm

 

A. Cărăuleanu, I.A. Tanasa, D. Nemescu, D. Socolov

Department of Obstetrics and Gynecology, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Introduction/objective. Vaginal birth after caesarean delivery (VBAC) is a controversial topic, considering the increasing number of elective repeat caesarean sections (ERCD), and the patient’s desire to achieve vaginal birth. The objectives of this study are to evaluate the VBAC trend in the last decade, and to summarize the existing data regarding the incidence, risk factors, benefits and harms associated with VBAC. Methodology. Reviews, meta-analyses and randomized controlled trials published between January 2010 and August 2020 were researched in MEDLINE and Cochrane databases. The data were extracted, summarized and statistically analyzed. Results. Twenty-one studies were included in this paper. The VBAC’s incidence was inhomogeneously distributed among different countries. The risks associated with VBAC were small, and no statistically significant difference was observed regarding the hysterectomies, the post-partum hemorrhages, or the transfusion rates between women who underwent VBAC and those who received ERCD. However, the uterine rupture risk was significantly higher in case of failed trial of labor after caesarean section (TOLAC). Conclusions. The safety profile of VBAC is good for eligible patients who undertook a careful prenatal evaluation, therefore it is necessary to reconsider the old obstetrical paradigm that states “once a caesarean, always a caesarean”. 

Keywords: VBAC, TOLAC, ERCD, vaginal birth

 

 

 

Pregnancy-related endocrine panel in the time of COVID-19

 

Mara Cârşote^1,2, Simona Elena Albu^3,4, Ana Valea^5,6, Cristina Vasiliu^3,4

1. Department of Endocrinology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

2. Department of Endocrinology, “C.I. Parhon” National Institute of Endocrinology, Bucharest, Romania

3. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

4. Department of Obstetrics and Gynecology, Bucharest University Emergency Hospital, Romania

5. Department of Endocrinology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

6. Department of Endocrinology, County Emergency Clinical Hospital, Cluj-Napoca, Romania

 

Introduction. COVID-19 pandemic changed our reality, including the medical, surgical and gynecological/obstetrical practice. Our aim is a 2020 literature update on endocrine-related issues on pregnancy during pandemic days. Materials and method. This a general review. Results. Due to changes at the level of anatomic respiratory tract, pregnant women are at higher risk of contracting SARS-CoV-2. The infection is more severe than in non-pregnant women. Angiotensin-converting enzyme (ACE-2) receptor that it is followed by the virus is highly expressed in pregnancy. Prior thyroid conditions do not associate a higher risk. Levothyroxine replacement goes according to pregnancy status. Antithyroid drugs display additional risks for agranulocytosis if the female is found positive. Thyrotoxicosis has higher risks of arrhythmia and thrombus in COVID-19 patients. Dopamine analogues for prolactinoma do not exert specific additional warnings. Particular aspects are the access to telemedicine for non-emergencies and the risk stratification based on individual assessment. Surgery for non-emergency tumors may be postponed. A special attention is needed to a massive risk of vitamin D deficiency due to lockdown, reduced physical activity and use of facial masks. Conclusions. COVID-19 pandemic days are associated with a higher risks for pregnant women. The particular endocrine aspects are hypovitaminosis D, access to routine thyroid and prolactin check-ups, and a risk stratification to avoid unnecessary exposure.

Keywords: pregnancy, thyroid, pituitary, COVID-19

 

 

 

Liver function tests and the evolution of delivery in women with intrahepatic cholestasis of pregnancy

 

Maria Cemortan

PhD student, “Nicolae Testemițanu” State University of Medicine and Pharmacy, Chişinău, Republic of Moldova

 

Introduction. Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-related condition characterized by the presence of cutaneous pruritus and modifications in liver function tests (LFTs). Materials and method. The retrospective study was performed by assessing 35 clinical cases of ICP in women admitted to the “Mother and Child” Institute, Chişinău, Republic of Moldova. Results. The mean age of women with ICP was 31.1±0.9 years old. Assessing the LFTs indicated the following mean values: alanine aminotransferase 71.8±13.8 U/l, aspartate aminotransferase 95.7±16.4 U/l, alkaline phosphatase 512±65.4 U/l. Relative leukocytosis was detected in four cases, the erythrocyte sedimentation rate was estimated in 25 women, in all cases the values were increased, the C-reactive protein was assessed in 12 cases, from which in three cases the values were increased up to 48 µ/ml. The total serum cholesterol level was assessed in 14 pregnant women, being increased in all cases; in 17 pregnant women with ICP (48.6%), hypoproteinemia was diagnosed. The birth occurred at less than 37 weeks in 45.7% of pregnant women. Delivery ended with a caesarean section in 45.7% of cases, of which in 62.5% emergency interventions were performed. Conclusions. Women with ICP present significant changes in LFTs during pregnancy, requiring numerous readmissions to specialized hospital units. The incidence of caesarean section among pregnant women with ICP was about 45.7% and a significant number of them were carried out urgently.

Keywords: intrahepatic cholestasis of pregnancy, obstetric cholestasis

 

 

 

Surgical menopause in reproductive women

 

Olga Cernetchi, Elena Vataman

“Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Republic of Moldova

 

Introduction. Surgical menopause is an issue with increasing significance in clinical practice due to its high frequency and increased morbidity. The aim of the study was to review the relevant literature data on surgical menopause in women of reproductive age. Materials and method. We performed a review of the currently available data in the PubMed database regarding the hormonal status and the effects of surgically induced menopause on women’s health. The keyword used for the search was “surgical menopause”. Results. Surgical menopause is a condition with the cessation of menstrual function that occurs in ovarectomy without hysterectomy, or ovarectomy with hysterectomy, or hysterectomy with the preservation of one or both ovaries, or after ovarian resection. In the case of the first two types, a severe estrogen deficiency occurs, and the first symptoms of surgical menopause develop very quickly, the vasomotor symptoms appearing already in the first two days after surgery. In case of hysterectomy with ovarian retention, in most women the symptoms of menopause appear gradually and seem to be similar but less dramatic compared to the first two cases. Studies show that surgical menopause involves serious health changes, including decreased bone density, cardiovascular disease, metabolic disorders, and mental health problems. Conclusions. Surgical menopause leads to a series of endocrine-metabolic, neurovegetative and psychoemotional disorders, due to the estrogen deficiency, which determines the need for an early diagnosis and the use of hormone replacement therapy.

Keywords: surgical menopause, menstrual function

 

 

 

Abnormal adherence placenta: will it become a common presence in obstetrics services?

 

Radu Chicea

Faculty of Medicine, “Lucian Blaga” University of Sibiu, Romania

 

The abnormal adhesion placenta increases in terms of incidence in all obstetrics services around the world, and Romania is no exception. Materials and method. The paper consists in analyzing data from the literature on predisposing factors, determinant factors, diagnosis and treatment possibilities of placentas with abnormal adhesion; then, we evaluated the five cases of placenta with abnormal adhesion in the last two years in the Obstetrics and Gynecology Clinic from Sibiu, under the aspect of the available diagnostic and treatment modalities, as well as the therapeutic management. Results. The analyzed cases were diagnosed by ultrasound examination, completed with MRI of the abdomen and pelvis, and the treatment was surgical, with four cases of hemostatic hysterectomy for maternal reasons and a case of placenta percreta presented extensively, with CT imaging and images from surgery procedures. Conclusions. The placentas with abnormal adhesion have become a pathology encountered more and more frequently in the obstetrics services in our country, with a rising incidence mainly due to the increase in the frequency of scar uterus.

Keywords: placenta with abnormal adhesion, case management

 

 

 

Epilepsy and pregnancy – case study of risks

 

Mădălina Ciuhodaru¹, Raluca-Ancuţa Tiperciuc², Cezar Rotaru², Maria Grosu², Diana Popovici¹, Doiniţa Turtureanu²

1. “Mother and Child” Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

 

Introduction. According to World Health Orga­ni­za­tion, the definition of a person’s well-being concerns the references to his/her sexual and reproductive behavior, including the ability to get pregnant and give birth. Nowdays, the debates regarding epilepsy and pregnancy are revealing that this pathology still offers the opportunity for motherhood if correctly approached. Methodology. The study took place on a 5-year period (2015-2019), with the aim to find out the risks and the colloquial consequences of pregnancy in women suffering from epilepsy. Most cases were from the rural area (11), aged 20-30 years old (8 cases), of which two didn’t properly took the antiepileptic medication. 99,8% of cases gave birth by caesarean section, with only two in expulsion, and 78% of cases (18) involved breastfeeding, the newborns being in 45% of cases prematures and 3% dysmatures. Conclusions. We need to apply particular methods of pregnancy monitoring, to adapt the specifc antiepileptic drug to each particular case, and to manage interdisciplinary the way of birth, considering the fact that all these might influence the weell-being of the mother and her baby.

Keywords: epilepsy, pregnancy, medication

 

 

 

Pregnancy and associated gynecological pathology – case study between 2015 and 2019

 

Mădălina Ciuhodaru¹, Diana Popovici¹, Maria Grosu², Raluca-Ancuţa Tiperciuc², Cezar Rotaru², Răzvan-Vladimir Socolov¹

1. “Mother and Child” Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

 

Introduction. Pregnancy is a relatively physiological event for any reproductive-age woman, marked by the potential existence of an associated gynecological pathology. In these cases, it might affect the ways of birth and the well-known protocols, transforming the pregnancy in one with high risk. Methodology. The study took place between 2015 and 2019, in the “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iaşi, to evaluate the different ways of approaching the births. Most cases were sided to renal areas,patients with ages between 30 and 35 years old -13 cases( 8 with fibromatosis and 5 with large ovarian cysts, two giants and three endometriotic). Nulliparous women were 10 cases From a total of 5250 births, the rate of C-section was 87%.82% of births were premature. Conclusions. Regular genital checkings (annual) should be implemented in order to find the best therapeutic approach to any gynecological pathology, lowering the risks for every pregnancy.

Keywords: fibroma, endometriosis, ovarian cysts, pregnancy

 

 

 

The influence of the treatment on the hormonal profile of nonpregnant women
with polycystic ovaries

 

Cristina Galeș, Carmen Lăcrămioara Zamfir

Department of Histology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

 

The influence of treatment with Yasmin® (ethinylestradiol and drospirenone) + spironolactone 50 mg/day orally in 21 non-pregnant women with polycystic ovary, aged 18-43 years old, was monitored for plasma free testosterone and dehydroepiandrosterone-sulfate (DHEA-S) levels. The patients were not diabetic and did not receive treatment with metformin or with another oral antidiabetes drugs. The diseases associated with polycystic ovary syndrome were dysmenorrhea, obesity and infertility. Laboratory determinations were performed before the beginning of the treatment and after 6 months of treatment. Chemoluminescence and ELISA techniques and commercial reagent kits were used. The results were interpreted statistically with the t test. There were no adverse effects in any of the patients that required the discontinuation or change of the treatment. The obtained data show that the level of plasma free testosterone decreases statistically significantly after treatment (2.84±0.26 pg/ml before treatment versus 1.75±0.31 pg/ml after treatment; p<0.05) and also decreases the DHEA-S concentration (386.3±18.2 µg/dl before treatment versus 257.9±14.3 µg/dl after treatment; p<0.05). No patient became pregnant during the study. Conclusions. The therapy with Yasmin® + spironolactone significantly decreases the level of the two hormones studied.

Keywords: polycystic ovary, testosterone, DHEA-S

 

 

 

Practical aspects on targeted screening in sexually transmitted diseases

 

Corina Grigoriu^1,2, Gina Ionescu Anculete², Alice Negru², Lucica Eddan Vişan², Anita Dudău²

1. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

2. Department of Obstetrics and Gynecology, Bucharest University Emergency Hospital, Romania

 

Introduction. Most sexually transmitted diseases (STDs) are asymptomatic, which leads to a high risk of transmission, as well as to long-term consequences: pelvic inflammatory disease (PID), infertility, chronic pelvic pain, dyspareunia. The universal routine screening for STDs is limited by the high, prohibitive costs for any healthcare system. However, for certain risk groups, the targeted or opportunistic screening for STDs has clear advantages – especially for young girls after the onset of sexual intercourse and in the first ten years after the onset, in mature women with high-risk sexual behavior and in pregnant women. Materials and method. We are presenting data from the literature regarding the targeted screening strategies of more advanced healthcare systems for Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), Trichomonas vaginalis, human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis A virus (HAV). Results. From the perspective of the gynecologist who faces the long-term consequences of STDs, asymptomatic or paucisymptomatic, undiagnosed and untreated, we highlight the necessity of an individualized approach as an opportunistic screening for these infections. We mention some of the most common situations in our current practice: patients with vaginal bleeding diagnosed with endometritis or endocervicitis, which have never been tested for Chla­my­dia trachomatis or Neisseria gonorrhoeae, patients with subfertility, patients with recurrent imbalances of the vaginal flora, obstetrical pathology – recurrent abor­tions and premature birth. Conclusions. The re­gu­lar gynecology consult, the recommendation of a con­tra­cep­tive method and the request for a preconception consult represent a few opportunities to apply the screening principles for STDs.

Keywords: sexually transmitted diseases, screening

 

 

 

Combined screening for aneuploidies in the first trimester. The experience of a medical center in applying the Fetal Medicine Foundation Protocol

 

Gheorghe Iliev¹, Mirela Tănase², C.M. Cozma², V. Gorduza³, Violeta Martiniuc⁴

1. “Dr. Gheorghe Iliev” Medical Center, Iași, Romania

2. Immunology Laboratory, “Dr. Gheorghe Iliev” Medical Center, Iași, Romania

3. Medical Genetics, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

4. Genetics Laboratory, “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

 

Introduction. We describe the experience of the “Dr. Gheorghe Iliev” Medical Center, Iași, Romania, in applying the combined screening protocol for aneuploidies of the Fetal Medicine Foundation (FMF), from London, UK, in the first trimester of pregnancy. Materials and method. We applied the quality standards recommended by FMF UK:

1. Sonographer certified by FMF for the 11-13-week scan.

2. Laboratory with FMF-certified analyzer.

3. Astraia software (FMF; first-trimester screening risk calculation software, module 2012). In cases with high risk of aneuploidy, we recommended prenatal genetic counseling, and therapeutic abortion in case of confirmed aneuploidy or severe malformations.

Results. Between 2.02.2010 and 30.06.2020, a total of 1542 pregnant women were screened. There were 445 (28.9%) pregnant women aged ≥35 years old. Based on the mother’s age, the population would have included 5.8 cases of trisomy 21 (T21) and approximately the same number of other chromosomal anomalies. The risk for T21 was ≥1/100 in 104 cases (6.6%). The risk for trisomy 18 (T18) and trisomy 13 (T13) was ≥1/50 in 18 and in 3 cases, respectively. Eighty-one pregnant women accepted chorionic villus sampling or amniocentesis. There were 13 cases of T21, eight cases of T18, two cases of  T13, three cases of triploidy, one case of  monosomy X, and four cases of structural chromosomal anomalies. Conclusions. Private healthcare services can provide quality standards recommended by FMF UK by recruiting competent personnel and providing suitable equipment. FMF UK protocol and screening algorithm ensures a high rate of prenatal diagnosis of aneuploidies.

Keywords: first trimester, combined screening, aneuploidies, trisomy 21

 

 

 

Diagnosis of obstetric, gynecological and extragenital maternal pathologies
in the first-trimester combined screening

 

Gheorghe Iliev

“Dr. Gheorghe Iliev” Medical Center, Iași, România

 

Introduction. This paper shows the role of obstetric ultrasound in the first-trimester combined screening for the diagnosis of obstetric, gynecological and extragenital maternal pathologies. Materials and method. During the first-trimester obstetric ultrasound, we examined the uterus, the cervix and the ovaries, and a pulsed Doppler exam was performed on both uterine arteries. We reassessed the obstetrical and gynecological pathology at 21-23 and 32-34 weeks of gestation. The cardiological examination was recommended in cases of maternal extrasystoles. Results. Between 2.02.2010 and 30.06.2020, we examined by ultrasound 1571 pregnant women, of which 1542 underwent the first-trimester combined screening. We identified 29 cases with early miscarriage (EM), 95 cases with low-lying placenta (LLP), 17 cases with marginal decidual hematoma (MDH), 103 cases of uterine myoma, 2 cases of cervical myoma, 12 cases of ovarian cysts, 13 cases of septate uterus, 6 cases of ovarian hyper­stimulation, one case with intrauterine device, and 33 cases with maternal extrasystoles (MES). Conclusions. The obstetric ultrasound from the first-trimester combined screening extended to the uterus, ovaries and uterine arteries can identify the early obstetric pathologies (EM, LLP, MDH), the gynecological pathologies, as well as ESM. The identification of this group of pregnant women with increased risk for the evolution of pregnancy can help improve the follow-up.

Keywords: first-trimester combined screening, low-lying placenta, early miscarriage, uterine myoma, ovarian cyst, septate uterus.

 

 

 

Non-chromosomal fetal malformations detectable during the first-trimester combined screening

 

Gheorghe Iliev

“Dr. Gheorghe Iliev” Medical Center, Iași, România

 

Introduction. We show the role of fetal ultrasound  in the early diagnosis of non-chromosomal fetal malformations during the first-trimester combined screening, the FMF-UK protocol. Materials and method. The evaluation of fetal anatomy in the first-trimester included the image of the head, brain, face, spine, heart (4 chambers, 3 vessels), stomach, abdominal wall, kidneys, urinary bladder and limbs. There are three categories of malformations diagnosed in the first trimester: a) always detectable (AD); b) never detectable (ND); c) sometimes detectable (SD). The second and the third fetal morphologies were performed at 21-23 and 32-34 weeks of gestation (WG). Results. Between 2.02.2010 and 30.06.2020, the screening was performed on 1542 pregnant women, of which 51 with twin pregnancies. We excluded 31 cases of aneuploidies and other chromosomal anomalies. During 12-13 WG, we diagnosed 32 cases with AD malformations and 17 cases with SD malformations. At 21-23 WG, we diagnosed 5 cases with ND malformations in the first trimester and 6 cases with SD malformations in the first trimester. At 32-34 WG, we diagnosed one case with SD malformation in the first trimester. Conclusions. At 11-13 WG, some anomalies are AD, some ND and others can be detected according to their association with increased nuchal translucency, the phenotypic expression of anomalies during pregnancy and the objectives established for foetal morphology. In order to maximize the prenatal detection of malformations, both the extension of the morphology protocol in the first trimester and additional examinations in the second and third trimesters of pregnancy are necessary.

Keywords: first-trimester combined screening, foetal malformations, prenatal diagnostic, ultrasound

References: Syngelaki A, Chelemen T, Dagklis T, Allan L, Nicolaides KH. Challenges in the diagnosis of fetal non-chromosomal abnormalities at 11-13 weeks. Prenat Diagn. 2011;31:90–102.

 

 

 

Conservative treatment of cervical cancer in pregnancy – case report

 

Anca Manta, P.C. Brătilă

Department of Gynecology, Euroclinic Hospital, “Regina Maria” Private Healthcare Network, Bucharest, Romania

 

The treatment of cervical cancer in pregnancy raises an ethical and medical dilemma. We present the cases of two pregnant women diagnosed with stage I FIGO cervical cancer. The first patient, 30 years old, was diagnosed with cervical lesion by Babeş-Papanicolau exam and colposcopy at 14 weeks of gestation. The cervical biopsy revealed the diagnosis of squamous cervical carcinoma with glandular invasion. The standard solution, proposed in other clinics, was radical hysterectomy along with the pregnancy, but the patient wanted to keep the pregnancy, as it was obtained spontaneously after five years of infertility. We proposed and performed conservative treatment: laparoscopic biopsy of the bilateral pelvic sentinel lymph node and radical vaginal trachelectomy. Pregnancy proceeded normally up to 38 weeks, when elective caesarean section was performed with the birth of a normal newborn. The second patient, 30 years old, with a caesarean section 14 months before, at 18 weeks of gestation, was diagnosed by Babeş-Papanicolau exam and colposcopy with a cervical lesion. Several cervical biopsies established the diagnosis of microinvasive cervical carcinoma. The treatment proposed in other clinics was the same as in the previous case, but the patient opted to keep the pregnancy. Taking into account the pregnancy age (20 weeks), we proposed and performed bilateral pelvic sentinel lymph node biopsy, abdominal uterine cerclage and trachelectomy with complete cervical occlusion. At 34 weeks of gestation, an emergency caesarean section was performed, with the birth of a healthy baby. Currently, both patients are under routine follow-up.

Keywords: cervical cancer, conservative treatment, pregnancy

 

 

 

Fresh versus frozen embryotransfer – advantages and disadvantages

 

Diana Mihai^1,2, Andreea Velișcu^1,2, Diana Comandașu^1,2, Cătălin Coroleucă^1,2, Ciprian Coroleucă^1,2, Claudia Mehedințu^2,3,
Alina Elena Bordea^1,2, Mihaela Braga¹, Elvira Brătilă^1,2

1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

3. Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, Bucharest, Romania

 

Introduction. The “freeze-all” (FET) strategy was considered by the international reproductive societies, as it was observed that the controlled ovarian hyperstimulation (COH) may have a negative impact upon the endometrial environment, affecting the implantation process or the development of the pregnancy. Methodology. We performed a systematic review, including 44 studies evaluating 278,000 newborns after ART, comparing the results of the classic ET versus “freeze-all” strategy. Results. The cumulative live birth rate (LBR) and pregnancy rate (PR) were significantly higher in the “freeze-all” strategy versus ET (LBR: 60.55% versus 45%; PR:RR 1.30 [CI 95%]). FET is associated with a lower obstetrical risk (CI 95%): the fetus has a lower risk of being small for gestational age (RR: 0.59), low gestational weight (RR: 0.74), premature birth (RR: 0.74), but a more increased risk for caesarean section (RR: 1.10) and large for gestational age (RR: 1.49). With regard to the risks of antepartum haemorrhage, placenta praevia, perinatal mortality, congenital anomalies and spontaneous abortion rate, there are no consistent findings: some studies concluded that the risk is lower in FET (0.67, 0.68, 0.8 and, respectively, 0,83), but most studies consider that there is no significant statistical difference. Gestational hypertension is controversial, some studies finding that it is more commonly linked to FET (RR: 1.29), but the results were insignificantly statistically different. However, FET is an independent risk factor for placenta accreta, three times higher than ET. Monozygotic monochorionic pregnancy after single embryo is lower in FET in general (0.8%), but maternal age below 35 years old is a risk factor in FET cycles. Conclusions. All this information makes the “freeze-all” strategy an eligible protocol in the future.

Keywords: cryopreservation, embryo transfer, freeze-all, in vitro fertilization, obstetric complications

 

 

 

Acute lymphoblastic leukemia in newborns with Down syndrome: literature review
and case presentation

 

Alina Mihăilă-Fecioru¹, Irina Profir^2,4, I. Munteanu^3,4, Alina Mihaela Călin^3,4

1. Depatment of Neonatology, “Sf. Apostol Andrei” County Emergency Clinical Hospital, Galați, Romania

2. Department of Pathological Neonatology, “Sf. Ioan” Emergency Clinical Hospital for Children, Galaţi, Romania

3. Department of Obstetrics and Gynecology, “Sf. Apostol Andrei” County Emergency Clinical Hospital, Galați, Romania

4. Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galați, Romania

 

Introduction. Children with Down syndrome have a predisposition to the development of leukemias in the neonatal period. There are three main subtypes speci­fic to this syndrome: transient leukemia, acute mega­karyo­blastic leukemia and acute lymphoblastic leukemia. Acute lymphoblastic leukemia is the entity with a predominantly unfavorable prognosis, despite the therapeutic intervention, with an incidence of 4.3-8.6:1,000,000 live births. Methodology. We analyzed the existing literature on this topic in order to establish the incidence of this pathology and the success rate of the applied protocols. We also used a case presentation from our clinic to exemplify the evolution and purpose of a newborn with this disease. Results. Down syndrome is one of the most common viable chromosomal abnormalities. Children and adolescents with Down syndrome have a 10-30% higher rate of leukemia than the rest of the pediatric population. At this time, in terms of acute lymphoblastic leukemia in the newborn, the treatment is mainly chemotherapeutic. There are no clear protocols regarding dose or frequency of administration. Most teams reported using cytarabine or vincristine with varying success rates. Discussion and conclusions. The case presented in our clinic supports the data from the literature, the evolution at 30 days resulting in death, despite the chemotherapy treatment initiated. Because Down syndrome is accompanied by multiple malignancies, with low rates of recovery and high rates of recurrence throughout life in survivors, both prenatal screening and prenatal counseling of parents receiving such a diagnosis is imperative for making the right decision.

Keywords: Down syndrome, screening, acute lymphoblastic leukemia

 

 

 

Aromatase inhibitors and selective estrogen receptor modulators to prevent
breast cancer

 

A. Milulescu^1,2, C.G. Viișoreanu¹, A.G. Filipescu^2,3

1. Breast Institute, Monza Hospital, Bucharest, Romania

2. Faculty of Medicine, “Titu Maiorescu” University, Bucharest, Romania

3. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

4. “Elias” University Emergency Hospital, Bucharest, Romania

 

Several previously published randomised clinical trials have shown that selective estrogen receptor modulators can reduce the risk of breast cancer in healthy women who are at high risk of developing breast cancer in the first 10 years of follow-up. Also, the IBIS-II trial compared anastrozole with placebo in order to determine the efficacy of anastrozole for preventing breast cancer (both invasive and ductal carcinoma in situ) in the post-treatment period. Findings. Between April 1992 and March 2001, 7154 eligible women recruited from breast care clinics from eight countries were enrolled into the IBIS-I trial and they were randomly allocated to the two treatment groups: 3579 to tamoxifen, and 3575 to placebo. After a median follow-up of 16 years, 601 breast cancers have been reported (251 in the 3579 patients from the tamoxifen group versus 350 in the 3575 women from the placebo group). The risk of developing breast cancer was similar between years 0-10 (226 in the 3575 women from the placebo group versus 163 in the 3579 women from the tamoxifen group), and after 10 years (124 in the 3295 women versus 88 in the 3343 women, respectively). The greatest reduction in risk was seen in invasive estrogen receptor-positive breast cancer and ductal carcinoma in situ, but no effect was noted for invasive oestrogen receptor-negative breast cancer. Between February 2003 and January 2012, 3864 women were recruited. A total of 1920 women were randomly assigned to 5 years of anastrozole, and 1944 to placebo. After a median follow-up of 131 months, a 49% reduction in breast cancer was observed for anastrozole. The reduction was larger in the first 5 years, still significant after 5 years, and not significantly different from the first 5 years. Invasive estrogen receptor-positive breast cancer was reduced by 54%, with a continued significant effect in the period after treatment. A 59% reduction in ductal carcinoma in situ was observed, especially in subjects known to be estrogen receptor-positive. No significant difference in deaths was observed overall or for breast cancer. A significant decrease in non-breast cancers was observed for anastrozole, owing primarily to non-melanoma skin cancer. No excess of fractures or cardiovascular disease was observed. The results from the meta-analysis provide important additional evidence that 5 years of tamoxifen treatment reduces the incidence of breast cancer in high-risk women for the entire follow-up period. The effect sizes for tamoxifen were significantly greater in women who did not take menopausal hormone therapy during the treatment period – a finding that has not been reported previously. No effect on all-cause or breast cancer mortality was recorded, but an increase in deaths from endometrial cancer was confirmed, as noted in the adjuvant trials. Conclusions. These results show that the use of tamoxifen and anastrozole offers a very long period of protection after treatment cessation, and thus substantially improves the benefit-to-harm ratio of the drug for breast cancer prevention.

Keywords: tamoxifen, anastrozole, IBIS-I, IBIS-II, breast cancer

 

 

 

Hyperthyroidism and pregnancy

 

R.A.M. Mogoș, D. Socolov, R.M. Haba, A. Cheaito, P.A. Prisecaru, A.V. Sescu, A. Cărăuleanu

Department of Obstetrics and Gynecology, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Introduction and objective. Thyrotoxicosis represents a complication in 0.1-0.4% of pregnancies. Methodology. We present the case of a 28-year-old woman with a six-week pregnancy and a history of treated Graves disease, apparently stabilized, with no therapy in the last year, who presented moderate signs of hyperthyroidism. Investigations: TSH (thyroid-stimulating hormone) = 0.035 µUI/mL (normal 0.4-4), fT4 (free thyroxine) = 28.42 pmol/L (normal 0.5-22.7), TRAb (thyroid autoantibodies) = 21 IU/L (normal ≤1.75). Results. From 11 weeks of pregnancy, avoiding the organogenesis period, the patient began the treatment with propylthiouracil, which has a moderate risk of fetal malformations, in a dose of 200 mg/day for 14 days and continued with 150 mg/day. From week 17, propylthiouracil was replaced with thiamazole 10 mg/day. At week 22, the fT4 level maintained at the upper limit of the normal values (18.35 pmol/L), with an important level of TRAb (14.24 UI/L), requiring the continuation of treatment with synthetic antithyroid drugs and the careful monitoring of the fetal development. Conclusions. Fetal morphometry was performed at 22 weeks and at 34 weeks. At 34 weeks, after fetal morphometry, it was recommended to pay attention to the postnatal intestinal transit to exclude a stenosis or duodenal atresia, gastroschisis being one of the few complications of the propylthiouracil administration. At 34 weeks, a new hormonal balance was performed which revealed FT4=13.66 pmol/L (normal) and important values of TRAb (0.2 IU/L). Caesarean section was performed. The male fetus weighed 3600 g and the APGAR score was 9. The TSH level at 4 days after birth was 126 µIU/mL, with normalization 14 days after birth (7.89 µIU/mL) and with fT4 within normal ranges. The particularity of this case is the occurrence of transient neonatal hypothyroidism, despite the administration of a moderate dose of synthetic antithyroid drugs.

Keywords: hyperthyroidism, antithyroid medication, fetus

 

 

 

Screening for cervical cancer is still an enigma

 

Iulian-Valentin Munteanu^1,2, Alina Mihaela Călin^1,2, Ana Maria Adam¹, Alina Mihăilă-Fecioru¹, Ana Maria Pâslaru¹

1. Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galați, Romania

2. Department of Obstetrics and Gynecology, “Sf. Apostol Andrei” County Emergency Clinical Hospital, Galați, Romania

 

Introduction. Cervical cancer is currently a major public health issue, accounting for 6% of all cancers in women. Romania has one of the highest incidences of cervical cancer and one of the highest mortality rates from this disease in Europe. The developing countries have a much higher incidence of this neoplasm, being the source of 85% of new cases, compared to economically developed countries, whose incidence is only 3.6% compared to new cases. This discrepancy highlights the success of the screening programs in which the periodic evaluation is performed through the Pap test. Materials and method. We present an observational study of 49 patients who have never been screened for cervical cancer, performed between June 2019 and January 2020. Results and discussion. The patients in the study group were between 26 and 64 years old, with a history of cervical dysplasia, most of them coming from financially disadvantaged or smoking environments, with multiple sexual partners, and a low educational level. The main cause of the development of cervical cancer in the patients from our observational study is the infection with human papillomavirus (HPV). HPV is a small, double-stranded, oncogenic DNA virus, due to the oncoproteins E6 and E7 that act by inhibiting p53 and pRB genes, responsible for tumor suppression. The most common HPV oncogene subtypes are: 16 (involved in 57% of cervical cancers) and 18 (involved in 16% of cervical cancers). HPV serotype 16 is a risk factor for squamocellular tumors, and HPV serotype 18 is commonly associated with cervical adenocarcinoma. Conclusions. The screening for the early detection of cervical cancer targets an expanded population segment, approximately 6 million women, with unfortunately only 12% currently covered. This is reinforced by the precarious socioeconomic conditions, with women in this category having limited access to screening programs. A decrease in the incidence of cervical cancer is expected in the future, as a result of the vaccine against the human papillomavirus.

Keywords: screening, cervical cancer, HPV, Pap test, cervical dysplasia

 

 

 

Nuchal translucency to diagnose early fetal anomalies

 

Dimitrie Nanu, Ali Al Delbani

Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Nuchal translucency (NT) is the normal fluid occupying the subcutaneous space between the back of the fetal skin and the overlying skin. An increased NT was first described as a measure greater than the 95^th percentile for a given crown rump length. However, reports have highlighted that opposing results are much more common with an NT that exceeds a set threshold of 3.5mm, a measurement that essentially represents the 99^th percentile or more throughout the gestational age window for the first-trimester screening. Assessing the thickness of NT has become a well-established method in early pregnancy for the detection of aneuploidy. NT measurement technique. Most experts recommend that NT should be measured between 11 and 13+6 weeks, corresponding to a CRL measurement between 45 and 84 mm. This gestational age window is chosen because NT as a screening test performs optimally and fetal size allows the diagnosis of major fetal abnormalities, thus providing women who are carrying an affected fetus with the option of an early termination of pregnancy. How to measure NT? A transabdominal or transvaginal route can measure NT. The fetus should be in the neutral position, a sagittal section should be obtained and the image should be magnified in order to include only the fetal head and the upper thorax. Furthermore, the amniotic membrane should be identified separately from the fetus. The median view of the fetal face is defined by the presence of the echogenic tip of the nose and the rectangular shape of the palate anteriorly, the translucent diencephalon in the center and the nuchal membrane posteriorly. If the section is not strictly median, the tip of the nose will not be seen and the orthogonal osseous extension at the frontal end of the maxilla will appear. The ultrasound machine should allow a measurement precision of 0.1 mm. Calipers would be positioned perfectly (on-on) to measure NT as the maximum distance between the nuchal membrane and the edge of the soft tissue overlying the cervical spine. If more than one measurement meeting all the criteria is achieved, the maximum one should be recorded and used for risk assessment. Conclusions. NT detection by ultrasound is considered as a powerful prenatal screening strategy to diagnose early fetal anomalies.

Keywords: nuchal translucency, ultrasound, fetal anomalies

 

 

 

Prophylactic cervical cerclage in the prevention of preterm birth in patients with history of preterm birth

 

Dimitrie Nanu, Ali Al Delbani 

Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Preterm birth, defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation, is a major determinant of neonatal mortality and morbidity and has long-term adverse consequences for health. Preterm birth rates have been reported to range from 5% to 7% of live births in some developed countries, but are estimated to be substantially higher in developing countries. Objective. To evaluate the prophylactic cervical cerclage in the prevention of preterm birth in patients with a history of preterm birth regarding gestational age at time of delivery. Methodology. The patients were selected from the outpatient clinic in Bucharest. Thirty-five patients were involved in this study. The study started in April 2011 and ended in December 2015 (the patients were selected according to inclusion and exclusion criteria). Results. The cervical cerclage was done at 12-14 weeks. We assessed the effect of cerclage taking into consideration the previous history of the patients .There was a reduction in preterm labour at 34 weeks (<34w=12 (34.28%) in comparison to (≥34 weeks =23 (65.71%) (P=0.0001) .Also it was noticed a reduction in preterm labour at 37 weeks (<37w=23 (65.71%) in comparison to (≥37 weeks =12(34.28%) (P=0.0006) highly significant.Conclusions. The prophylactic cervical cerclage did prevent preterm delivery in these patients.

Keywords: prophylactic cervical cerclage, preterm birth, preterm labor

 

 

 

Kidney transplantation and pregnancy – a synthesis and analysis of literature

 

M. Petică¹, D. Huțanu¹, D. Popescu¹, M. Onofriescu^1,2

1. Department of Obstetrics and Gynecology, “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

2. Department of Obstetrics and Gynecology, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Introduction and objective. Reproductive function for patients with chronic renal failure tends to improve after transplantation. However, pregnancy is a test due to the various complications associated with allograft physiology. Methodology. We performed a meta-analysis of the literature associated with cases treated in our clinic in the last five years, highlighting the complications and results of those tasks. Results. Out of 15 cases evaluated in our clinic in the last five years, 11 patients gave birth to live fetuses and 4 patients had miscarriage; the associated complications were preeclampsia (4 patients), gestational diabetes (one patient) and pregnancy-induced hypertension (4 patients); the mode of birth was caesarean section (10 patients), natural birth (one patient) and premature birth (4 patients). The average gestational age was 35.3 weeks, and the average birth weight was 2550 g. Discussion and conclusions. Despite the fact that pregnancies with kidney transplantation require a careful counseling of the patient and that the risk of maternal and fetal complications is increased, the results in pregnancies with live fetuses are favorable. However, it should be borne in mind that the number of abortions is increased and that creatinine modification may pose an increased risk of allograft loss.

Keywords: transplant, complications, creatinine, pregnancy

 

 

 

The relevance of HPV testing in the screening for cervical dysplasia

 

Daria Maria Pop¹, Renata Lăcrimioara Nicula¹, Ciprian Porumb¹, Florin Laurențiu Ignat², Doru Diculescu¹, Dan Mihu¹

1. “Mother and Child” Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

2. Department of Surgery and Gynecological Oncology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

 

The incidence of cervical cancer in Romania is three times higher than in the rest of the European Union, and the mortality rate of such a pathology is the highest of all the European countries. Since cervical cancer can be prevented in approximately 80% of the cases through screening programs, it is necessary to determine and implement optimal screening and triage strategies. Traditionally, cervical cancer screening was based on cervical cytology, specifically Pap smears, but nowadays, given the fact that persistent infection with HPV high-risk types leads to cervical cancer, HPV testing becomes a logical alternative. The screening for HPV infection can be accomplished by self- or provider-collected HPV testing, within a primary or secondary HPV screening program. Several studies have shown that combining HPV testing with Pap smears saves additional years of life while also being cost-efficient. Implementing sustainable prevention programs that use HPV testing along with Pap smears can result in decreased incidence and mortality rates from cervical cancer, as long as the appropriate HPV testing method is chosen for each given category inside the general population. Knowing the relevance of each HPV testing method leads to cost-efficient prevention programs that patients are more likely to follow-up.

Keywords: HPV testing, cervical cytology, cervical cancer, high-risk human papillomavirus, cervical dysplasia

 

 

 

Intrahepatic cholestasis of pregnacy and stillbirth: a systemic analysis of the cases
from the “Cuza Vodă” Hospital between 2015 and 2020

 

D. Popescu¹, D. Huțanu¹, M. Petică¹, M. Onofriescu^1,2

1. Department of Obstetrics and Gynecology, “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

2. Department of Obstetrics and Gynecology, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Introduction. Obstetric cholestasis (or intrahepatic cholestasis of pregnancy) appears in the third trimester of pregnancy, having as main symptom pruritus. The etiology of obstetric cholestasis is undoubtedly multifactorial, with genetic, environmental and hormonal factors having important roles. Objectives. This analysis shows the link between obstetric cholestasis and one of the most important outcomes, stillbirth, reviewing cases from the “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, between 2015 and 2020. Methodology. The obtained data were subjected to a rigorous quality assessment and followed by interpretable results. Results. The data show a high rate of complications, such as preterm birth and stillbirth, and a higher rate of caesarean sections. Discussion. The results of this analysis will represent a benchmark in the future medical practice, stillbirth remaining one of the most devastating complications of this pathology.

Keywords: obstetric cholestasis, stillbirth, preterm birth

 

 

 

Candidiasis in pregnancy

 

Diana Popovici^1,2, Mădălina Ciuhodaru^1,2, Georgiana-Alexandra Marian-Bogdan², Raluca-Ancuţa Tiperciuc², Andreea Doboș²

1. “Mother and Child” Health Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

2. Third Department of Obstetrics and Gynecology, “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

 

Introduction. Candidiasis is a fungal infection (cau­sed by Candida albicans) that develops in conditions of appropriate temperature, moisture and environment, and it can be located in the mucosa, especially in the mouth and vagina, but also in some other internal organs like the esophagus and the intestine. Methodology.Candida albicans can be usually found in the human body, living in balance with the rest of the saprophytic microbial flora. There are certain risk factors in its occurrence and development, such as: hormonal changes during pregnancy, dehydration, diabetes, overuse of oral contraceptives, of antibiotics or corticosteroids. After birth, it can also be located in breasts – areola and lactiferous ducts. Symptoms consist in the appearance of white spots on the oral mucosa with an underlying congestive background, painful itch, sometimes feeling like a burning in the breast or in the pharynx or esophagus, depending on location, or difficulty swallowing. The definitive diagnosis is made after scraping and cultivation on the Sabouraud agar, by visualizing the micelles under the microscope. Conclusions. The prophylactic treatment involves maintaining a rigorous hygiene, avoi­ding excessive and unprotected use of antibiotics and increasing the body’s immunity through a balanced diet and through the intake of mineral salts and vitamins. The curative treatment can be local, using creams, shampoos, mouth water, gentian violet, boro-glycerin, or general, using oral or parenteral lapachol, ketoconazole and, more recently, fluconazole. The latter are not given to pregnant women because of their side effects.

Keywords: candidiasis, pregnancy, lapachol, ketoconazole, fluconazole

 

 

 

 

Incidence of diabetes in pregnancy – case study

 

Diana Popovici¹, Georgiana-Alexandra Marian-Bogdan², Raluca-Ancuţa Tiperciuc², Andreea Doboș²

1. “Mother and Child” Health Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

2. Third Department of Obstetrics and Gynecology, “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

 

Introduction. Diabetes is a syndrome characterized by a complex disorder of the body’s energy metabolism, which involves changes in carbohydrates, proteins and lipids. The association between pregnancy and diabetes enhances a negative evolution of the pregnancy and of the mother’s diabetes as well. The evolution of pregnancy is categorically influenced by diabetes, both in terms of pregnancy and the fetus. The evolution of diabetes is more serious in pregnant women and acquires a new entity: gestational diabetes. Diabetes has an unfavorable influence regarding pregnancy by increasing the number of miscarriages, with a higher incidence of fetal anomalies (hydramnios) and intrauterine death. Methodology. The study was performed over a period of two years, between 2017 and 2019, at the “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iaşi, to evaluate the incidence and the complications caused by diabetes in pregnancies from a total of 1890 births. The incidence was higher in pregnant women from the age category over 30 years old (76% of cases), in the category of 20-29 years old (14.6% of cases), while in the category under 20 years old there were only 9.4% of cases, being most frequent in women with a first birth compared to women who had more than one child. Of these, only 18.94% were supraponderal and macrosomial newborns, 14.8% were underweight and 66.26% had a normal weight. Conclusions. The multidisciplinary team has an important role in the management of diabetes in pregnancy (obstetrician, diabetologist and general practitioner), for the early detection, individualized treatment, the prevention of diabetes complications and for the post-delivery follow-up.

Keywords: gestational diabetes, pregnancy, macrosomial newborns

 

 

 

Incidence and influence of toxoplasmosis in pregnancy – case study between 2015 and 2019

 

Diana Popovici¹, Mădălina Ciuhodaru¹, Raluca-Ancuţa Tiperciuc², Oana Neumann², Andreea Doboș², Georgiana-Alexandra Marian-Bogdan²

1. “Mother and Child” Health Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

2. Third Department of Obstetrics and Gynecology, “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

 

Introduction. Toxoplasmosis is an infection caused by the Toxoplasma gondii protozoan, cats being the permanent hosts. The prevalence of the parasite depends on the geographic area and its genotype. More care should be provided to the pregnant woman, who must be informed, diagnosed and treated in time. The majority of infections concerning the mother do not affect the pregnancy, they are subclinic. For the immunocompetent people, the initial infection provides immunity and the infection before pregnancy eliminates any risk of vertical transmission. The maternal infection presents itself with a four times higher risk of prematurity. The incidence and the severity of the maternal toxoplasmosis depend on the moment of infection and the gestational age. The risk of fetal infection increases with the duration of pregnancy. Methodology. The study was performed over a period of five years (2015-2019), at the “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iaşi, to provide a better view on the incidence and influence of toxoplasmosis in pregnant women. Most cases of toxoplasmosis were concentrated in rural areas, in the group age of 20-29 years old (41 cases; 67%), in women with more than one pregnancy (66 cases; 84%), in total 87 cases (2%) from 5250 pregnancies and births from the obstetric department and 15 cases (17%) from the neonatology department. Conclusions. The general practitioner, who needs to report all toxoplasmosis cases in pregnant women and colaborate with the obstetrician, plays a very important role. The detection is made through serological tests (TORCH profile), after which we choose an individualised treatment for each pregnant woman.

Keywords: toxoplasmosis, pregnancy, cats, TORCH

 

 

 

Central placenta praevia with major hemorrhage in the external genital area –
conduct in case of a premature fetus in pelvic presentation

 

Diana Popovici¹, Andreea Doboș², Raluca-Ancuţa Tiperciuc², Georgiana-Alexandra Marian-Bogdan², Mihai-Gabriel Marin²

1. “Mother and Child” Health Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania

2. Third Department of Obstetrics and Gynecology, “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology, Iași, Romania

 

Introduction.Placenta praevia represents a major cause of bleeding in obstetrics, often endangering the woman’s life or having psychoemotional influences due to the consequences they cause (hemostasis hysterectomy). Methodology. A 23-year-old patient, pregnant in 35 weeks, presented at the emergency room with important bleeding in the genital area, without painful uterine contractions, with pelvine presentation and intact membranes. The patient had anemia (hemoglobin=9.2 g/dL). The fetal ecobiometry indicated a 35-week gestation, with a unique fetus in complete pelvic presentation, with active fetal movements and present fetal cord movements, and placenta praevia covering the internal orifice of the cervix. The diagnosis was 35-week first gestation, unique living fetus, complete pelvic presentation, intact membranes, triggered premature birth, central placenta praevia, and major bleeding on the genital area. Results. An urgent caesarean section was performed, a live newborn was transplacentary extracted – a male fetus, weighing 2100 g, with an Apgar score of 5 at one minute and 8 at five minutes. The hemostasis was difficult but efficient. Postoperatively, hemoglobin=7g/dl, hematocrit=28.26%, corrected through erythrocyte concentrate transfusion (hemoglobin=9 g/dl). Favorable evolution at the discharge. Conclusions. The diagnosis of placenta praevia presents itself with increased bleeding risk, the need of a blood transfusion and hemostasis hysterectomy surgery. Placenta praevia remains an important pathology in pregnancy, where a correct hospitalization and the careful management of the delivery play a crucial role.

Keywords:placenta praevia, bleeding, hemostatis hysterectomy

 

 

 

The importance of TORCH panel testing in childbearing women

 

Mihaela Corina Radu^1,2, A.C. Boeru¹, Mihaela Liliana Marin¹, Loredana Sabina Cornelia Manolescu²

1. Obstetrics and Gynecology Hospital of Ploieşti, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Various infectious agents encountered during the gestational period are important because they influence both the maternal and fetal health and may cause congenital malformations in the fetus by crossing the placental barrier. Pregnancy-related physiologic changes suppress the immunity for a certain period and thereby enhance susceptibility to infectious agents. Among these, Toxoplasma gondii, rubella and cytomegalovirus (CMV) are the most frequently encountered. Materials and method. The studied cases are of childbearing women who gave birth at the Obstetrics and Gynecology Hospital of Ploieşti in the 2017-2018 period. Two groups were selected from a total of 7020 pregnant women, the entire group of women that gave birth during the two-year period. Childbearing women with adverse obstetric antecedents, respectively spontaneous abortions, pregnancies stopped in evolution, stillbirths, intrauterine growth retardation, premature births or congenital birth defects, were included in the main studied group. The control group consisted of childbearing women without an adverse obstetric antecedents or history, and was extracted from the same source. The study was carried out in compliance with the rules of medical ethics, the patients expressing their informed consent regarding the use of their data from the observation sheets and the use of the results of the clinical and laboratory investigations. There were 286 childbearing women, classified in two groups, namely: Group A, the main group, consisting of 143 childbearing women with unfavorable obstetric history, and Group B, the control group, consisting of 143 childbearing women without adverse obstetrical history. Our research aimed at demonstrating that maternal exposure to a certain number of infectious agents, if investigated in a standardized manner, can provide objective pregnancy surveillance in order to reduce adverse effects such as fetal mortality and morbidity. Results.Serological and molecular investigations for Toxoplasma gondii. In the main group, 49.79% of childbearing women presented antibodies against Toxoplasma gondii and in the control group only 11.68% presented these antibodies. Out of these, 32.45% women from the main group presented IgG antibodies, respectively 9.08% in the control group. For IgG and IgM antibodies, the seropositivity was 12.03% in the main group, and 3.7% in the control group. Toxoplasma DNA determinations identified only 8 cases of infection in the risk group and one case in the control group. Serological and molecular investigations for rubella. The presence of IgM antibodies against rubella was revealed in very few cases. There was no statistically significant difference between the control group and the studied group. Moreover, the two, respectively one case in which IgM antibody against rubella were present were not confirmed by molecular tests. Serological and molecular investigations for cytomegalovirus (CMV). There were only three cases in which IgM antibodies against CMV infection were detected, without any statistical significance between the control group and the studied group. From the two cases, respectively one case of IgM seropositivity, the molecular tests confirmed the presence of CMV DNA only in one case from group A. Serological and molecular investigations for herpes simplex type 2. There is no significant difference between the control group and the group of women with an unfavorable pregnancy history. In addition, because only the presence of IgM antibodies is important for fetal risk, as it signifies an acute infection or a reactivation, the number of positive cases for IgM antibodies of herpes simplex virus (six and respectively two cases) showed a difference between the two groups, also insignificant. Serological and molecular investigations for parvovirus B19. There were no cases of infection with B19 parvovirus, the serological and molecular tests revealing the same results. Serological and molecular investigations for varicella shingles. There were no cases of infection with varicella-zoster virus, the serological and molecular tests revealing the same results. Conclusions. We found an association between the adverse obstetrical history and an increased pregnancy risk in the case of infections with Toxoplasma gondii. In all other determinations, the results showed no association. In the light of these data, we suggest a reconsideration of the data set of tests required.

Keywords: TORCH, Toxoplasma, rubella, CMV, herpes simplex

 

 

 

 

Depressive pregnancy disorder – clinical case presentation

 

Mihaela Corina Radu^1,2, A.C. Boeru¹, Oana Roxana Dumitrescu¹, Mihaela Liliana Marin¹, Loredana Sabina Cornelia Manolescu²

1. Obstetrics and Gynecology Hospital of Ploieşti, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Depression is very common in women, especially in women of childbearing age. It is estimated that 14-23% of pregnant women suffer from depression during pregnancy and 5-25% experience postpartum depression. Methodology. This article presents a case of depressive disorder in a 41-year-old pregnant woman, whose pregnancy and birth have been successfully completed. It also reviews the updates from the literature. Discussion. The regular checkups at the specialist most often approach the physical aspects of pregnancy development (measurement of the fetus, mother’s weight etc.), with rare questions regarding the mother’s mental state, especially the less pleasant experiences, or regarding the life context. There is no biological marker indicating depression, the only way to measure the intensity and evolution of depression is by means of evaluation scales. The evaluation scale is not a unique diagnostic mode and is never used individually to establish a diagnosis or to replace the clinical evaluation. Conclusions. The positive diagnosis of depressive disorder is difficult to establish due to the heterogeneity of the notion. The clinical examination, with a careful observation of the patient, the knowledge of behavior prior to depression, the history of the disease, and of family and personal history stressors, can help diagnose the case.

Keywords: depressive disorder, pregnancy, depression

 

 

 

HPV infection in pregnancy – clinical case presentation

 

Mihaela Corina Radu^1,2, A.C. Boeru¹, Oana Roxana Dumitrescu¹, Mihaela Liliana Marin¹, Loredana Sabina Cornelia Manolescu²

1. Hospital of Obstetrics and Gynecology of Ploieşti, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Introduction. Human papillomavirus (HPV) is known as one of the most common causes of genital infections in sexually active women. The virus is transmitted mainly sexually, but epidemiological and clinical studies suggest sufficient evidence for other routes of transmission. Newborns can contract the infection intrauterinely, perinatally or through horizontal transmission. Clinical case presentation. Patient S.I., 34 years old, employee, unmarried. Personal physiological history: menarche at 12 years old; menstrual cycle – regular, 28 days; average duration of 3-5 days, moderate menstrual flow about 3-4 absorbents/day; she denies phenomena associated with menstruation; no births; abortions – one spontaneous at 8 gestational weeks, an abortion on request. Personal pathological history: appendicectomy in 1999. Heredocollateral antecedents: she denies family diseases, she denies chronic diseases. Living and working conditions: house with two rooms, low average monthly income, she denies alcohol consumption, she has been smoking about 10 cigarettes per day for 11 years, she drinks coffee (1 cup per day), she has no stable partner. Local physical examination: normal pubic hair, vulvar hyperpigmentation, normal anal sphincter, tonic and continent, vulvar cauliflower-shaped voluminous formation, leucorrhea secretion inside vagina in a moderate amount, cervix dilated with 2-3 cm, intact membranes, skull applied, painful uterine contractions at 5 minutes lasting for 20 seconds, fetal heartbeats – 146 beats per minute. The ultrasound examination revealed intrauterine pregnancy with a single live fetus in left occipitoiliac presentation (biparietal diameter): 89 mm, HC (cranial circumference): 317 mm, AC (abdominal circumference): 315 mm, FL (femur length): 67 mm, amniotic fluid in normal amount, AFI: 15 cm, estimated fetal weight: 2500 g, gestational age: 37 weeks with symmetrical development, cardiac activity present, fetal heartbeat within normal limits, placenta inserted anteriorly. The anamnestic data and the clinical and paraclinical examinations support the diagnosis: IIIG IP, pregnancy of 37 weeks, live fetus. Occipitoiliac left cranial presentation, intact membranes, labor, bulky vulvar condylomatosis. Once the diagnosis is established, the birth by caesarean section is indicated. Discussion. During pregnancy, due to the changes that occur, the maternal body is in a stage of physiological immunosuppression, being more prone to contract infections. Thus, the main route of HPV transmission is the vertical transmission, from mother to fetus or newborn, during pregnancy, prenatally, and at birth, perinatally, a hypothesis supported by the fact that the viral types identified in the mother were the same as those identified in the newborn. The transmission can also occur at the time of fertilization or contraception, through the infected sperm, the virus being identified in semen and sperm in a variable proportion of 8-64%. The transmission is most common during spontaneous birth, being described as the classic mechanism of contracting the infection. Conclusions. The high heterogeneity of the effects that HPV has on pregnancy and the newborn makes it necessary to conduct studies with the same or almost the same HPV detection methods and on a larger population.

Keywords: HPV, pregnancy, genital infections

 

 

 

Vaginal progesterone, cerclage, pessary for premature cervical remodeling and preterm birth prevention. Pregnancy outcome

 

Manuela Russu, Adriana Ghelmene, Şerban Nastasia

Department of Obstetrics and Gynecology, “Dr. I. Cantacuzino” Clinical Hospital, Bucharest; Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine
and Pharmacy, Bucharest, Romania

 

Introduction. Preterm birth is a burden for the developing countries, and premature cervical remodeling (PCR) correction may be a preventive and/or a therapeutic option. Objectives. The assessment of outcomes in the treatments with vaginal progesterone, cerclage or pessary for PCR in singleton pregnancies. Methodology. This is a retrospective study at three years monitoring of three groups of patients with PCR: Group A – vaginal progesterone and cerclage (8); Group B – vaginal progesterone and pessary (62); Group C – vaginal progesterone, cerclage and pessary (13). The patients were treated in the “Dr. I. Cantacuzino” Clinical Hospital, Bucharest, a Romanian third-level maternity. Analysis: demographics, obstetrical history (cervical pathology, miscarriages, preterm births), vaginal/cervical infection, other treatments associated to procedure. Primary outcomes: gestational age (GA) and cervical lenght at initiation, GA (weeks) and fetal weight (g) at expulsion; route of birth; Apgar score, composite neonatal morbidity; hospitalization (days), maternal comorbidities. The statistic analysis was performed with JMP IN software; the correlations reached the statistical significance for a p value Results. The mean maternal age (years): 31.87/27.76/29.66; mean parity: 1.25/1.51/1.58; cervical length at intervention (cm): 2.72/2.06;1.69; genital infections: (5):50/20/16.67; pulmonary maturation (%): 50/61.67/16.67; mean GA at intervention: 20.12/27.27/19.08. Outcomes: birth GA 37.37/36.58/34.91, with two miscarriages (A/B); caesarean section (CS)/vaginal (%): 100/0;55/45’50/50; weight: 3340/2743/2703; mean Apgar score: 8.25/8.45/7.66; respiratory distress syndrome (RDS; %): 0/33.33/6.67; mechanical ventilation (%) 12.5/3.33/25 and surfactant (%):0/5/25. Hospitalization: 5.37/8.38/16.33. One neonatal death (B), no maternal death, and nonstatistically significant maternal morbidity. Conclusions. The early identification of cervical premature remodeling helps for a longer pregnancy prolongation (p<0.0001), better neonatal outcome p

Keywords: progesterone, cerclage, pessary, preterm birth

 

 

 

Preeclampsia: screening, prevention management and risk factors. The International Federation of Obstetrics-Gynecology versus the American College of Obstetrics-Gynecology

 

Viorela-Elena Suciu¹, R. Ciortea^1,2, A. Măluțan^1,2, C. Iuhaş^1,2, R. Mocan-Hognogi^1,2, Carmen Elena Bucuri^1,2,3, Maria Rada¹, Marina Dudea^1,2, Adelina Clim¹, Denisa Berindean¹, D. Mihu^1,2

1. “Dominic Stanca” Clinic of Obstetrics and Gynecology, Cluj-Napoca, Romania

2. “Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

3. “Dr. Constantin Papilian” Military Emergency Clinical Hospital, Cluj-Napoca, Romania

 

Preeclampsia is a multisystemic disease, with a preva­lence of 2-5%, that affects pregnant women. Every year, 76,000 women and 500,000 fetuses die due to the complications of this pathology. The prenatal screening for preeclampsia is constantly being updated. Globally, attempts are being made to identify easily reproducible, cost-effective screening markers that determine with great accuracy the patients prone to develop preeclampsia. Thus, there are differences between the described risk factors, the screening and prevention protocols recommended by world-recognized medical associations, such as the International Federation of Obstetrics-Gynecology (FIGO) and the American College of Obstetrics-Gynecology (ACOG). According to the latest FIGO recommendations, all pregnant patients should be screened in the first trimester for preeclampsia, including: maternal risk factors, mean blood pressure, placental growth factor and uterine artery pulsatility index. Patients at increased risk of developing preeclampsia will undergo preventive treatment with aspirin between 11-14 weeks +/- 6 days and 36 weeks of pregnancy. ACOG presents patients with a history of preeclampsia, multiple pregnancy, chronic hypertension, type 1 or 2 diabetes, kidney disease or autoimmune diseases as having an increased risk of developing preeclampsia and a need for the prophylactic administration of aspirin. There is also a difference between the risk factors presented by the two associations. In conclusion, the determination of screening markers that provide an increased identification of patients at risk of developing preeclampsia, as well as the precise determination of risk factors for preeclampsia are imperative to anticipate and initiate the preventive treatment for women at risk, decreasing the prevalence of the disease, its complications and implicitly the costs.

Keywords: preeclampsia, screening, pregnancy

 

 

 

Uterine fibroma in pregnancy

 

Mihaeala Camelia Tîrnovanu¹, Cristian Negură², Ştefan Dragoş Tîrnovanu³, Doina Pancu²

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

3. “Sf. Spiridon” County Emergency Clinical Hospital, Iaşi, Romania

 

Literature underestimates the prevalence of fibroids in pregnancy and overestimate the complications attributed to them. Objective. We analyzed the maternal and fetal prognosis in pregnant women admitted to a tertiary level maternity hospital, the influence of age and BMI on the fibroids presence, and also the suitability to perform myomectomy at birth. Materials and method. The prospective study was performed between January 2017 and June 2019, and included 57 patients with fibroids in pregnancy (0.75% of all births). Results. The age range was between 25 and 45 years old (with only 11% of obese patients). 68% of fibroids were diagnosed in the third trimester of pregnancy. Most often, the fibroid had the maximum growth in the last trimester of pregnancy. The presence of fibroids in pregnancy determined: four abortions, five premature births, eight threatenings of premature birth and eight imminences of abortion, nine premature ruptures of membranes, and one case of abruptio placentae. Regarding the fetus status, we found: four cases of dystocic presentation, three cases of intrauterine growth restriction, two cases of small weight for gestational age, and a single Apgar score of 4. Nineteen cases had praevia fibroids. Myomectomy was performed on 12/49 caesarean sections. Ante- and postpartum hemoglobin showed a decrease of 1.76% for the group without myomectomy and 2.95% for those with myomectomy. Conclusions. 40-45% of the women were between 30 and 34 years old. Nulliparity plays an important role in the etiology of fibroids (68.28%). The fibroids growth was continuous, only five cases showing a decrease in size in the third trimester, compared to the second trimester. The size of the fibroids is not important for the way of delivery.

Keywords: uterine fibroma, pregnancy, myomectomy

 

 

 

Pregnant women screening for group B Streptococcus in 2020 and a review of literature data

 

Mihaela Camelia Tîrnovanu¹, Roxana Corduneanu², Bogdan Toma², Alexandra Iov³, Vlad Gabriel Tîrnovanu³

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

3. PhD Student, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Group B Streptococcus (GBS) normally colonises the bowel of 20-30% of adults. Vaginal colonization is transitory in 18% of pregnant women. Objective. To establish the GBS presence in women who gave birth, between October 2019 and September 2020, in the First Clinic of Obstetrics Iaşi, and the implications on the mothers’ and newborns’ condition. Materials and method. The study analyzed the pregnancy screening for GBS, the interval from membrane rupture until birth, the condition of mothers and newborns, and the inflammatory parameters. Results. A total of 192 cases had GBS in cultures – 32 on screening, 16 on vaginal discharge at hospitalization, 54 on amnioculture, and 90 on lochia culture. Out of 120 patients with antenatal care, only half were screened for GBS (28 absent and 32 present – 53.33%). Twenty-four patients gave birth by caesarean section. During puerperium, half of the women had hemorrhoids. The mothers or the newborns had no clinical manifestations of infection. The evolution of newborns was monitored through leukocytes and CRP. The interval from the membrane rupture to birth was over 18 hours in 12 patients. Ampicillin was administered to patients with positive screening. Twelve children were treated with amikacin, while the others were on antibioprophylaxis with ampicillin for three days. Conclusions. Although the number of pregnant women in care is increasing, the screening for GBS was made for 50% of them. Streptococcus was also present in cultures of patients with negative screening, explained by the vaginal collection without concomitant sample from the anus. The literature mentions that obesity increases the incidence of portage – in this study, only 6.25% of the subjects were obese.

Keywords: GBS, vaginal colonization, pregnancy

 

 

 

The manifestation of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME)Maria & Irina Vasilieva syndrome

 

Irina Vasilieva^1,3,5, Maria Vasilieva^1,3,5, I. Vasiliev^{1,3,4,5,6,9,11,12}, M. Malakhova^4,6, S. Groppa^2,3,5, G. Ghidirim^2,3,5, L. Tofan-Scutaru^3,5, Valentina Diug^3,5, P. Vanevsky⁴, M. Gavriliuk^2,3,5, I. Moldovanu^2,3,5, Tatyana Globa^1,3, C. Iavorschi^1,2,3, Ninel Revenco^2,3,5, Mirta D’Ambra^1,7, P. Globa^2,3, A. Visnevschi^1,2,3, P. Bujor³, Elena Globa³, Larisa Spinei^1,2,3, I. Catereniuc^1,2,3, G. Caradja³, V. Nacu^1,2,3, N. Bacinschi^2,3, V. Dumitraș^1,3, N. Rotaru^1,3, V. Vovc^1,2,3, G. Stoleriu^1,8, L. Globa^1,3, I. Stavrou^1,10, V. Vartanov^1,11, G. Litarczek¹²

1. World Academy of Medical Sciences,  The Netherlands (WAMS)

2. Academy of Sciences of the Republic of Moldova

3. “Nicolae Testemițanu” State University of Medicine and Pharmacy, Chişinău, Republic of Moldova

4. ATI Department, “V. Vanevsky” Medical Institute for Continuing Education of Physicians, St. Petersburg, Russia

5. Institute of Emergency Medicine; Institute of Neurology and Neurosurgery; Mother and Child Institute, Republic of Moldova

6. Laboratory of Experimental Pneumology, Medical Institute for Continuing Education of Physicians, St. Petersburg, Russia

7. Department of Medical Sciences, University of Medicine of Buenos Aires, Argentina

8. “Dunărea de Jos” University og Galați, Romania; Enna Faculty of Medicine and Pharmacy, Italy

9. Via - Intosana Private Medical Unit, Republic of Moldova

10. Disciplinary Department of the Hellenic Society for Pain Management and Palliative Care, Athens Medical School, National and Kapodistrian University of Athens, Aretaieion University Hospital, Greece

11. ATI Department, State University of Medicine, Samara, Russia

12. Influenza Institute, St. Petersburg, Russia

13. Fundeni Clinical Institute, Bucharest, Romania

 

Primary/secondary functional injury of cell membranes with deterioration of ionic potential of membrane electrical potential (MEP) bio-electromagnetic field, quantum energy and quantum electromagnetic radiation, such as signal transfer, which involves pathophysiological responses of the pathophysiological cellular act is considered as Maria&Irina Vasilieva syndrome (Electro-Ion Membrane Distress Syndrome; EIMDs), which causes chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). EIMDs and mitochondrial acidosis internally established by disordered depolarization decrease selectively MEP of the inner mitochondrial membrane, where ATP decreases ubiquinone (CoQ10 synthesis is reduced) and the mitochondrial energy deficiency is established, during which the pores are damaged, Ca⁺⁺ uniporter mPT pore, channel KACh, ChitoATP/MitoATP ratio, receptors: adenosine A1; purine P2, the metabolome of nitric oxide as well as aqua pore are involved. Immunocompromise (IC) CHAOS dissonance creates an electro-storm disorder or electroparalysis of MEP, and the persistence of cytokines induces the postresuscitation disease described by G. Litarczek, P. Safar and V. Negovsky. In the IC CHAOS survivors, a marker of CFS/ME was the study of the reduced erythrocyte deformation, E from the blood, which accompanies EIMDs, evaluating the membrane permeability and the absorption capacity of E, an osmometer dependent on the urea concentration. The traditional therapy in IC CHAOS survivors with dissonance did not ensure a steady decrease in CF/ME, the effect of which was observed after MOST-ELSO therapy associated with cryobioxeno (thymomyelospleno) extracorporeal perfusion. The slightly symptomatic CFS/ME observed after cryobioxeno perfusion was also considered as a universal bio mechanism of cryotherapy expressed by the effect of compression and reduction of “synairesis” proteins, by separating the liquid from the gel, caused by the reduction of water and the cell membranes and cells from deuterium D/²H, “heavy water” which inhibits some cleavage reactions.

Keywords: CFS, ME, IC, CHAOS

 

 

 

Impact of the TRUFFLE study on the management of pregnancies with fetal growth restriction before 32 weeks

 

Radu Vlădăreanu^1,2, Anca Burnei-Rusu^1,2, Theodora Ștefania Mardale¹

1. Department of Obstetrics, Gynecology and Neonatology, “Elias” University Emergency Hospital, Bucharest

2. “Carol Davila” University of Medicine and Pharmacy, Bucharest

 

The diagnosis and management of fetal growth restriction (FGR) remain an unresolved dilemma in modern obstetrics. Advances in neonatal care in recent decades have led to improved survival of preterm infants, even at very early gestational ages. However, morbidity, neurological impairment and low intellectual and social performance are still involved and strongly associated with the gestational age at birth. There is currently no effective treatment to change the course of FGR, to prevent hypoxemia, acidemia, fetal deterioration and even intrauterine fetal death, except delivery. FGR is probably among the obstetric entities where there is the greatest variation in medical practice, in terms of monitoring and recommended gestational age for delivery. The TRUFFLE study (The Trial of Randomized Umbilical and Fetal Flow in Europe) was a prospective, multicenter, randomized trial designed to learn what methodologies should be used to monitor pregnancies with early-onset FGR and which criteria should trigger the delivery, with a primary outcome of survival at the age of 2 years old without cerebral palsy or severe neurosensory impairment or with a Bayley III development score >85. In this regard, the TRUFFLE study compared two fetal monitoring techniques – Doppler examination on ductus venosus, and computerized cardiotocography – from which short-term variability of the fetal heart (STV) can be established. The perinatal death was uncommon (8%) and 70% of newborns survived without severe neonatal morbidity. The intervals from inclusion in the study to birth/death and severe morbidity were influenced by the presence and severity of the maternal hypertensive conditions. The findings have led to significant discussions at national and international levels in order to include this study in the following specialized protocols.

Keywords: FGR, prematurity, cardiotocography, ductus venosus, Doppler, TRUFFLE

 

 

 

summaries of the National Congress of Uroginecology,

27-28 November 2020

 

 

 

Single-thread perineovaginoplasty (Bader perineovaginoplasty)

 

Alexander Bader

Bader Medical Institute of London, United Kingdom

 

Introduction. Vaginal laxity and prolapses represent a real issue in gynecology. They have a significant impact for the patient’s quality of life, especially when the woman is young, sexually active and at a reproductive age. Frequently, the conventional methods can affect negatively the outcomes and would not meet the patients’ expectations. Introducing the single barbed thread technique could be an innovative method to overcome such issues. Nevertheless, high skills in pelvic floor surgery are needed, the knowledge of the anatomy is required, and the case selection is important. Methodology. Using single barbed thread with two needles would be an alternative method to repair vaginal laxity and pelvic organs prolapses. The method involves the full posterior vaginal canal correction with a single barbed thread. The most important advantage of this method is to avoid necrotic zones, eliminating the loss of sensation and keeping the pelvic floor functional after vaginal surgeries. Results. It seems that the results register a very high rate in terms of efficacy, safety and patient’s satisfaction. I have been performing the same method for nine years, with an average of 80 cases per year, and I had zero complications and not even one adverse result. All patients report being happy with the results. Conclusions. It seems that the single barbed thread application is safe and with important advantages compared to conventional methods. The technique is easy to learn and it eliminates the pelvic floor discomfort for patients after such kind of procedures.

Keywords: vaginal laxity, prolapse, single thread

 

 

 

The efficiency of alternative nonsurgical treatment for stress urinary incontinence
and mixed urinary incontinence

 

Mihaela Boț

Department of Obstetrics-Gynecology and Neonatology, “Elias” University Emergency Hospital; “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Urinary incontinence affects 10-45% of women with the age between 15 and 64 years old. Many of these women claim urinary incontinence as being disturbing and others perceive this illness as a true infirmity, thus being a pathology which negatively influences the quality of life. The most frequent types of urinary incontinence among women are stress urinary incontinence and mixed urinary incontinence. Stress urinary incontinence is the most frequent type of urinary incontinence and the International Society of Continence defined it as the involuntary leakage of urine under stressful conditions, such as sneezing, coughing or laughing. A number of treatments are currently available for urinary incontinence, with the main purpose to reduce the occurrence of involuntary loss of urine episodes, lowering the negative impact on life quality and even improving it. The International Society of Continence recommends the pelvic floor physical therapy for urinary incontinence, as a first-line treatment. Pelvic floor physical therapy proved good and very good functional results, has low costs, it is minimally invasive, with low rates of side effects and – most important – it increases the quality of life for these patients.

Keywords: stress urinary incontinence, nonsurgical treatment for urinary incontinence, mixed urinary incontinence

 

 

 

Herlyn-Werner-Wunderlich syndrome: a rare cause of acute abdomen after acute urinary retention and hematometrocolpos in adolescents (poster)

 

Ioana Adelina Clim¹, R. Ciortea^1,2, D. Diculescu^1,2, A. Măluţan^1,2, Carmen Elena Bucuri^1,2,3, Mihaela Oancea^1,2, Maria Patricia Rada¹,
Marina Dudea-Simon^1,2, Viorela Suciu¹, D. Mihu^1,2

1. “Dominic Stanca” Clinic of Obstetrics and Gynecology, Cluj-Napoca, Romania

2. “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania

3. “Dr. Constantin Papilian” Military Emergency Clinical Hospital, Cluj-Napoca, Romania

 

Introduction. Herlyn-Werner-Wunderlich syndrome (HWW) is a rare congenital anomaly of the urogenital tract characterized by the triad: uterus didelphys, obstructed hemivagina and unilateral renal agenesis, which is two times more common on the right side than on the left side. The incidence of this syndrome is 0.1-3.8% and, so far, in less than 10 cases the association of this pathology with acute urinary retention has been reported. Materials and method. We present the case of a 13-year-old girl who came to our emergency room accusing pain of increased intensity in the lower abdominal floor, started insidiously a week before, accompanied by nausea, pallor, sweating, anxiety and moderate vaginal bleeding (menstrual status). The anamnesis revealed absent diuresis for about 6 hours, menarche at 12 years old, regular menstruation, oligomenorrhea and dysmenorrhea. The clinical examination revealed respiratory movements of the abdomen, distension caused by a pseudotumoral mass located subumbilically, reluctant, painful; normal external genitalia. The paraclinical examination (ultrasound and MRI) revealed: voluminous cystic mass of 155/100/100 mm located between the bladder and the rectum, suggestive of hematometrocolpos; lower it protruded into the vagina, the image being suggestive of the transverse vaginal septum; uterus didelphys; normal ovaries and fallopian tubes. Unseen left kidney – left renal agenesis. Results. Surgery was performed with urinary bladder catheterisation, incision of the septum and continuous aspiration – about 1000 ml of chocolate-like fluid, suggestive of old blood, followed by resection of the vaginal septum. Conclusions. A high rate of awareness and clinical suspicion of HWW syndrome among adolescents is necessary for both the diagnosis and the prompt surgical treatment, leading to remission of symptoms, prevention of complications and to preservation of fertility.

Keywords: hematometrocolpos, acute urinary retention, urogenital malformation, uterus didelphys, renal agenesis

 

 

 

Surgical methods of neovaginoplasty for radiation-induced vaginal stenosis
and Mayer-Rokitansky-Küster-Hauser syndrome

 

A.G. Filipescu^1,2, Andreea Grațiana Boiangiu^1,2, Saphia Pârvulețu Ali¹, Oana Alina Solomon¹

1. Department of Obstetrics-Gynecology, “Elias” University Emergency Hospital, Bucharest, Romania

2. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

An important criterion for women’s quality of life is an active sexul life, any sexual dysfunction causing its decrease. Radiation-induced vaginal stenosis and Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome cause sexual dysfunction, which is why their treatment is important in order to increase the quality of life. The most well-known and safest method of treatment is neovaginoplasty, which aims at returning the patient a functional vagina. Cervical, uterine, vaginal or anorectal neoplasm treated with pelvic radiation therapy and/or brachytherapy has as a complication vaginal stenosis. Two-thirds of all patients treated with pelvic radiation therapy/brachytherapy develop vaginal stenosis in the first year. Pelvic radiation therapy causes vaginal fibrosis, which in turn leads to stenosis of varying degrees. Depending on the degree of stenosis, the patient may have dyspareunia, postcoital vaginal bleeding, or in the case of a complete vaginal stenosis, she may experience the impossibility of sexual contact. Mayer-Rokitansky-Küster-Hauser syndrome occurs in 1 in 4,500 girls and affects mainly the reproductive system, being characterized by the absence of the development of the uterus, vagina, or both. The most common diagnosis is made around the age of 16 years old, when the patient goes to the doctor for primary amenorrhea. The patients diagnosed with MRKH syndrome characterized by complete or partial absence of the vagina have sexual dysfunctions, from dyspareunia to the impossibility of sexual intercourse. In the absence of treatment, the two pathologies lead to a poor quality of life, which is characterized by both physical and mental suffering. In conclusion, in both vaginal stenosis and MRKH syndrome, neovaginoplasty plays an important role in increasing the quality of life, and for this reason, several surgical techniques are described.

Keywords: Rokitansky syndrome, stenosis, neovaginoplasty, treatment

 

 

 

Pudendal nerve block for iatrogenic hemivulvodynia

 

Attila Fogarassy¹, Diana Mihai^2,3, Elvira Brătilă^2,3, Florina Todoruț¹

1. Gyniclinique, Timișoara, Romania

2. “Prof. Dr. Panait Sirbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

3. Department of Obstetrics-Gynaecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Objectives. This case report serves the purpose of evaluating the efficiency of an alternative treatment for the women who are suffering from vulvodynia. Materials and method. After the correct diagnosis of a iatrogenic hemivulvodynia with vaginal atrophy and vaginismus, we applied different solutions for the treatment of a patient, and we observed whether the symptomatology subsided or disappeared. We used different treatments, such as laser therapy for vaginal atrophy, non-linked hyaluronic acid for vaginal dryness, external personalized creams with anesthetics, antidepressants (amitriptyline) and antispastics (baclofen) for vulvodynia, and botulinum toxin injections in different sites for vaginismus and vulvodynya. Results. Every treatment method that we applied to the patient had a benefit for her well-being, but the most satisfying result came after the pudendal nerve block with botulinum toxin. Conclusions. Pudendal nerve block with botulinum toxin is an efficient treatment for vulvodynia.

Keywords: vulvodynia, vaginismus, vulvovaginal atrophy, botulinum toxin, pudendal nerve, pain management

 

 

 

Multimodal approach in the treatment of vaginismus

 

Raluca Hera

Hera Medical Institute, Bucharest, Romania

 

Introduction. Vaginismus is a relatively common condition in women of all ages and has physical and psychological consequences. The Multimodal Botox Program helps women overcome this condition, restores the quality of life and allows a normal sexual life and family planning. Methodology. The Multimodal Botox Program uses a combination treatment: botulinum toxin injections into the spastic pelvic floor muscles, under local or general anesthesia, followed by a progressive dilation program, counseling and support. After the accurate diagnosis and classification of vaginismus using clinical examination and a questionnaire, 50 patients have been treated during the last 4 years using the Multimodal Botox Program treatment protocol. After the procedure, all patients were followed-up during one year. They were recommended to follow a strict dilation program during 6-12 months. Sexual intercourse was allowed after 2-16 weeks post-procedure, depending on the severity of the vaginismus. Results. The Multimodal Botox Program demonstrated a 100% success rate. Successful sexual intercourse was possible after 2-4 months. Pregnancy occurred in four patients during follow-up. None of the 50 patients needed a second injection. Two patients failed our follow-up program. Conclusions. The Multimodal Botox Program is a highly effective treatment protocol for vaginismus of all grades, significantly improving the quality of life, the sexual life and the family planning.

Keywords: vaginismus, botox injection, genital botulinum toxin, multimodal treatment, progressive vaginal dilatation, vaginismus treatment

 

 

 

As a minimal invasive procedure, COG threads intravaginally are used for tightening

and treatment of mild SUI

 

Ozgur Leylek

Female Clinic, Istanbul, Turkey

 

Objectives. This presentation aims at showing that COG threads can be used intravaginally for nonsurgical vaginal tightening and for the treatment of mild SUI (stress urinary incontinence). Introduction. There are many types of threads used in aesthetic medicine. The development in their production technology made their domain of usage more wider than before. In recent years, threads have entered the cosmetic gynecology as a new field. In our study, we aimed to show the efficiency of COG (barbed) threads for rejuvenation, tightening and lifting of vaginal mucosa. Materials and method. The subjects were chosen from the patients who applied to our clinic for sexual pleasure deficiency related to vaginal relaxation, and we excluded the other patients who had POP (pelvic organ prolapse) or/and other systemic contraindications. Under the local or sedation anesthesia, we inserted the threads into the vaginal mucosa by our three techniques, VTT-L (vaginal thread tightening – longitudinal) and VTT-C (vaginal thread tightening – circular) for vaginal tightening, and PUTL (periurethral thread lifting) for the treatment of mild SUI. All patients who were applied VTTL or VTTC were evaluated by FSFI scoring (Female Sexual Function Index) and by a 5-point Likert scale measuring the patient satisfaction before and after the procedure, while the patients who are applied PUTL were evaluated by urinary diary before and after the procedure. Results. We determined that vaginal COG applications tighten the vagina by mucosal thickening with biological and mechanical effects. As a result, we found an acceptable difference between before and after scoring of the validated questionnaires, and most of the patients declared that the results were good or very good. Conclusions. Although there aren’t any published studies about intravaginal COG thread applications in literature yet, and we could not have a sufficient number of patients, most of the women included in our study declared that they were satisfied with the results. We believe that intravaginal thread applications can be an alternative to other nonsurgical or surgical vaginal tightening and therapeutic SUI methods in the future.

Keywords: SUI, COG threads, vaginal tightening

 

 

 

CO₂ fractional microablative laser for menopausal vulvovaginal atrophy –
clinical and histopathology results

 

Diana Mihai^1,2, Diana Comandașu^1,2, Cătălin Coroleucă^1,2, Ciprian Coroleucă^1,2, Elvira Brătilă^1,2

1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Objectives. This is a review of literature, highlighting the results of the use of pulsed CO₂ laser for the treatment of vulvovaginal atrophy (VVA) in postmenopausal women. Methodology. We included 11 clinical studies and 3 histopatological studies, involving more than 1500 participants. All patients received three laser sessions, one at every 4-6 weeks. All studies included an examination before the procedure, then one after each session. Some studies included evaluation at follow-ups at 3, 6, 12, 18 and 24 months. We selected the studies based on the same evaluation scales: Visual Analog Scales (VAS), Vaginal Health Index Scores (VHIS), Female Sexual Function Index (FSFI) and Short Form 12 questionnaires (SF-12), and the participants’ satisfaction was measured on a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). These scales were used to assess pain, vaginal burning, vaginal itching, vaginal dryness, dyspareunia and dysuria. Results. The data indicated in all available publications a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia; p<0.001) and overall, after 3 sessions, 92.58% of thepatients were satisfied or very satisfied. In the long-term studies, the satisfaction of the patients at 6 months was 92%, at 12 months it was 82.66%, at 18 months it was 63%, and at 24 months it was 25%. The objective histological measurements of the effect of laser therapy improved significantly as well. Conclusions. Histological and clinical evidence supports the use of CO₂ lasers in the treatment of VVA. The long-term data showed that the improvement of vaginal health continues up to 12 months after fractional CO₂ laser treatment, and progressively decreses up to 24 months.

Keywords: vulvovaginal atrophy, CO₂ laser, menopause, dryness

 

 

 

PRP use in gynecology

 

Diana Mihai^1,2, Diana Comandașu^1,2, Cătălin Coroleucă^1,2, Ciprian Coroleucă^1,2, Elvira Brătilă^1,2

1. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

2. Department of Obstetrics-Gynecology and Neonatology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

 

Objectives. Platelet-rich plasma (PRP) is gaining more and more popularity as a minimally invasive option for a series of disease, therefore it is important to be informed about the potential use and indications of this therapy. Platelets stimulate the natural healing process of tissue, having 5- to10-fold higher concentration of growth factors than the whole blood, and in the same time no side effects. Methodology. This is a literature review highlighting the results of the use of PRP in different gynecological pathologies. Results. Platelets promote healing and attract stem cells to the site of the injury, thus they stimulate the natural healing process. PRP can be successfully used for faster re-epithelialization in the treatment of cervical ectopy or vulvar dystrophy (lichen sclerosus, kraurosis vulvae), for obtaining lower rates of wound infection, necrosis and wound dehiscence, and shorter recovery time in breast and vulvar reconstructive surgery and in fistulae treatment. In addition to these, it has been shown that PRP addition with absorbable and nonabsorbable vaginal meshes used in pelvic floor reconstructive procedures is associated with a better functional outcome. Nevertheless, PRP plays an important role in reproductive medicine, when used in premature ovarian failure for “ovarian rejuvenation”, in ovarian torsion for a better reperfusion, in intrauterine infusion for a better endometrial growth and receptivity. In vitro, it is demonstrated to seal amion tears and enhance membrane healing, preventing the premature rupture of membranes. Last but not least, PRP is used in aesthetic gynecology, including female sexual dysfunction (O-Shot, G-Shot therapy, vaginal rejuvenation). Conclusions. PRP is a simple but effective therapeutic modality to treat numerous noninvasive or minimally invasively gyneologic conditions, it  has no side effects, and it is worth to be studied on a large scale and clinically used.

Keywords: vulvovaginal atrophy, gynecology PRP, lichen sclerosus, sexual function

 

 

 

Bone marrow aspirate concentrate(BMAC): a ray of hope and a therapeutic alternative for women with impaired ovaries (premature ovarian failure or primary ovarian insufficiency)

 

Prabhu C. Mishra¹, Sheryl Palad², Diana Mihai³, Poonam Mishra⁴, Nidhi Jha⁵

1. StemMax Research & Therapeutics Pvt Ltd., New Delhi, India

2. Holy Family Medical Center, Angeles City, Republic of the Philippines

3. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

4. Manas Hospital, Lucknow, India

5. Malviya Nagar Private Clinic, New Delhi, India

 

Introduction. Stem cell-based therapies are emerging enormously as a ray of hope and a therapeutic alternative for ovarian rejuvenation, regeneration and follicular development in women with impaired ovaries mainly due to primary ovarian insufficiency or premature ovarian failure. In all cases of ovarian impairment, such as poor ovarian response and diminished ovarian reserve or primary ovarian insufficiency, there remains a need for methods to restore fertility in patients seeking reproductive success, but where oocyte donation had been the only practical option. As per the studies reported, within the ovarian context, the infusion of the whole population of human bone marrow-derived stem cells promote human follicle growth, ovarian local vascularization, increase follicle and stromal cell proliferation, and reduce apoptosis and atresia, providing an adequate ovarian niche for follicular rescue in patients with impaired or aged ovarian reserve. Methodology. Based on this, we aimed to evaluate the effects of autologous bone marrow-derived stem cell ovarian transplant on the ovarian reserve of poor responder women with very poor prognosis. With this purpose, we designed a method to mobilize, collect and deliver bone marrow-derived stem cells directly to human ovaries. Bone marrow aspiration done from ileac crest and BMAC concentrate prepared and infused to patient by laparoscopy in ovaries and other group PRP have been injected into ovaries stroma by transvaginal injections. Results. This unique study developed in patients showed that autologous bone marrow-derived stem cell ovarian transplant improves the ovarian reserve biomarkers and reproductive outcomes, resulting in more follicles and oocytes developed after ovarian stimulation. Conclusions. This technique allowed spontaneous pregnancies in poor responder women previously limited to egg donation, but further research is still needed as the embryo euploidy was not modified by the stem cells therapy. The diagnostic hormonal levels improved post-procedure; there was a reduction in FSH and an increase in AMH and in estradiol levels.

Keywords: bone marrow-derived stem cells, BMAC, premature ovarian failure, primary ovarian insufficiency, FSH, AMH, estradiol, PRP, MSC

 

 

 

Pelvic and prolaps surgery in the new COVID-19 era... and again the same question:
to mesh or not to mesh?

 

Andrei Mueller-Funogea

Department of Gynecology, St. Antonius Hospital, Eschweiler, Germany

 

Pelvic organ prolapse (POP) is an anatomic condition that can dramatically influence the female’s quality of life. The high rate (more than 40%) of reoperation for recurrence, after native tissue repair (traditional classical surgery), and evidence that mesh insertion is an effective treatment for hernia surgery favored the introduction of mesh for POP repair. POP repairs by vaginal approach can be technically difficult and have a flate learning curve. Transvaginal mesh repair for POP was introduced to the market in the 1990s as an alternative to traditional native tissue repair and quickly became widely used, although the level of evidence was poor. Several studies showed the recent years’ success. That was in the past. Based on the recovery of anatomy, it was recently redefined to include the absence of symptoms and correlation with patient subjective perception and outcomes.Open abdominal sacrocolpopexy with mesh has become a standard technique for patients with uterovaginal prolapse. However, abdominal approach has been substituted by less invasive laparoscopic and robotic techniques. Vaginal repair with mesh has the same goal as the abdominal/laparoscopic approach, but the uterus can be conserved and the anatomy can be better restored. A Cochrane review reports that transvaginal mesh is associated with lower rates of reoperation for prolapse than native tissue repair, but is also associated with higher rates of stress urinary incontinence, or mesh exposure and with higher rates of de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is still no evidence to support this position. In 2011, many transvaginal meshes were voluntarily withdrawn from the market in USA, and the fewer lightweight transvaginal meshes still available have not been evaluated within a randomized controlled trial. The complication rates of vaginal mesh seem to differ based on the accuracy of procedure, and much more on surgeon experience. In Germany, the need of certification of the surgeon by the mesh-producer is obvious. Regarding the uterine sparing surgery, high satisfaction and low reoperation rates can be reached using a variety of vaginal hysteropexy techniques. With regard to anterior compartment prolapse, to reduce the rate of recurrent prolapse after traditional anterior colporrhaphy (native tissue surgery), clinicians have used different surgical techniques with mesh. A milestone was surely the discovery of the transobturator suspension by Delorme. Native tissue repair was associated with increased risk of repeating surgery for prolapse and recurrence of anterior compartment prolapse compared with polypropylene mesh repair.  Current evidence does not support the primarly use of mesh repair compared with native tissue repair for anterior compartment prolapse owing to increased morbidity. Surgeons and patients should be cautious when using these products, as their safety and efficacy have not been established on the long term. Complications may still occur after many years. Currently, the evidence-based medicine recommendations are:

1. Fascial surgery remains fundamental in primary POP surgery, especially for young, sexual active patients.

2. Mesh could be used in prolapse relapses and in POP>stage 3 and in elderly women.

3. Possible use of mesh in primary surgery only with adequate patient selection and risk assessment.

4. Polypropylene (with or without titanium coating) meshes should be chosen.

5. Anterior meshes with apical fixation may be used; transperineal meshes should be critically used in the posterior compartment prolapse correction due to the high risk of complications.

Keywords: pelvic organ prolapse, surgery, mesh, polypropylene

 

 

 

Quality of life with transvaginal mesh cervicosuspension at sacrospinous ligaments
for genital prolapse (poster)

 

Şerban Nastasia^1,2, Adriana Ghelmene², Manuela Cristina Russu^1,2, Anca Simionescu^1,3

1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

2. Department of Obstetrics and Gynecology, “Dr. Ion Cantacuzino” Clinical Hospital, Bucharest, Romania

3. “Filantropia” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

 

Objectives. We performed a prospective study for the evaluation of the patient’s quality of life (QoL) with transvaginal mesh cervicosuspension at sacrospinous ligaments for genital prolapse. Methodology. The surgical correction of the genital prolapse was performed by using mesh sacrospinous ligaments cervicosuspension. PFIQ-7 and PFDI-20 questionnaires were used to evaluate the impact of bladder, bowel or pelvic symptoms on the patient’s quality of life. Both questionnaires were fulfilled before surgery and six months after. Nocturia was included as an additional question in PFDI-20 questionnaire. Results. During the interval 2017-2019, the cervicocolposuspension at sacrospinous ligaments was performed in 28 cases of genital prolapse. The questionnaires PFIQ-7 and PFDI-20 were filled in preoperatively and at 6 months postoperative interval by 25 patients. The complete data were available in 20 patients. The grade of pelvic prolapse was 4 in eight cases (40%), 3 in nine cases (45%), and 2 in three cases (15%). The PFIQ-7 preoperative and postoperative median scores for bladder/urine, bowel/rectum and vagina/pelvis questions were 6, 0, and 3.5, versus 1, 0, and 0, respectively (p<0.001). The PFDI-20 preoperative and postoperative median scores were 25.5 and 3, respectively (p<0.001). The preoperative and postoperative nocturia median scores were 2 and 0, respectively (p<0.001). Conclusions. Transvaginal mesh cervicosuspension at sacrospinous ligaments is improving the QoL in patients with grade 3-4 genital prolapse correction.

Keywords: genital prolapse, transvaginal mesh, sacrospinous ligaments cervicosuspension, QoL

 

 

 

Radiofrequency in genital aesthetic

 

Jha Nidhi¹, Prabhu Mishra², Diana Mihai³, Dutta Indranil⁴, Grover Aneesha⁵

1. Care and Cure Clinic, New Delhi, India

2. StemMax Research & Therapeutics Pvt Ltd., New Delhi, India

3. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics an Gynecology, Bucharest, Romania

4. Department of Obstetrics and Gynecology, IQ City Medical College, Durgapur, India

5. Southend Fertility and IVF Centre, New Delhi, India

 

Introduction. Aesthetic gynecology is undoubtedly a fast-growing subspecialty with increasing demand for a variety of procedures to beautify the female genitals. It would typically include procedure(s) to enhance, reduce or refashion various anatomical components of the female genitals, so as to cumulatively improve the aesthetic appearance of the female genitals. Radiofrequency energy is a form of electromagnetic current that can be delivered through various tissue types (i.e., skin, fat and muscle) to generate thermal energy. Radiofrequency (RF) was initially used in medicine in the 1920s for electrocautery. Over the past 15 years, its use in aesthetic surgery has increased. Science behind radiofrequency. In 2002, FDA approved the first monopolar RF device for facial wrinkle reduction (ThermaCool; Thermage, Inc., Hayward, California). Since 2002, more sophisticated RF devices have been developed to deliver RF energy in different manners (i.e., bipolar, multipolar and fractional) with more safety features. Unlike lasers, RF does not target specific chromophores by selective photothermolysis. Instead, RF generates heat as a result of different tissue resistance or impedance to the electromagnetic current. When RF energy is applied to the underlying skin and soft tissue, it generates contraction by two mechanisms: (1) immediate cleavage of hydrogen bonds in the collagen triple helix, causing shortening and thickening of the collagen fibrils, and (2) initiation of a wound healing cascade to trigger neoangiogenesis, neocollagenesis and elastin reorganization over the following 3-4 months. These processes along with growth factor infiltration restore the elasticity and moisture of the underlying vaginal mucosa. Heat shock protein activation and inflammation activation are also considered to be the underlying mechanisms of action. Methodology. Multiple prospective small case series studies have reported outcomes of women treated with radiofrequency system. Typically, three treatments at an interval of 4 to 6 weeks were applied. The clinical endpoint temperature had a range of 40°C to 45°C, which was maintained for 3 to 5 minutes per treated zone during 30 minutes’ total treatment time. Results. An improvement in vaginal laxity symptoms was reported in some patients after three treatments. They also reported subjective improvements in both vaginal atrophy symptoms and sexual function. No serious adverse effects were reported in these case series. In another trial, the radiofrequency device was studied in a cohort of 25 sexually active women with self-reported anorgasmia or increased latency to orgasmic response. Six patients received three treatments four weeks apart. Approximately 75% of the participants reported improved orgasmic responsivity, vaginal lubrication and clitoral sensitivity. The authors suggested sustained treatment benefits at 9 to 12 months. A confirmatory randomized, multicenter US-based trial is currently underway. At present, the VIVEVE I trial remains the only published, large-scale, randomized, sham-controlled, blinded study of a radiofrequency-based treatment. Conclusions. Radiofrequency treatments were well tolerated and were associated with improvement in vaginal health and with the amelioration of symptoms of vaginal laxity and vaginal dryness, but more studies are required for a better understanding.

Keywords: aesthetic gynecology, vaginal laxity, vaginal atrophy, sexual function, orgasm

 

 

 

Genital fat grafting – regenerative and wellness healthcare of the new normal

 

Sheryl S. Palad¹, Prabhu Mishra², Diana Mihai³

1. Holy Family Medical Center, Angeles City, Republic of the Philippines

2. StemMax  Research & Therapeutics Pvt Ltd., New Delhi, India

3. “Prof. Dr. Panait Sîrbu” Clinical Hospital of Obstetrics and Gynecology, Bucharest, Romania

 

Introduction. Aging leads to physical and functional changes. In our facial features, lines and wrinkles become more evident. Contoured and youthful appearance disappears as we loss the fat volume in the particular area. With the concept of women wellness, we provide care for both the upper and lower face of women represented by vulvar area.The mechanism of aging is almost the same for the said areas, hence the loss of volume leads to loss of cushion and protection that leads to possible pain and discomfort during sexual activity. Fat grafting/transfer provides the answer to aesthetic and functional gynecology. The abundance of fat deposition in different parts of the body is an advantage that provides a natural source for the procedure with the progress in regenerative medicine by adding PRP in the fat graft procedure viability and quality is achieved.Methodology. First is the cosmetic and aesthetic improvement of the vulvar, particularly the labia majora area, and  secondly are the concerns of functional sexual dysfunction secondary to loss of cushion leading to pain and discomfort during sexual activity. The surgical approach is done to improve the labia majora due to loss of volume, secondary to aging, and even the extreme changes in women’s weight. The procedures include fat harvesting, tumescent application, and low negative pressure is applied for the fat harvesting. Fat preparation with platelet-rich-plasma mixed with the fat tissue for grafting. 15-20 ml of fat is injected in the subcutaneous layer of each labia. Results. The fat transfer technique creates labia majora enhancement, resulting in a more youthful appearance. The procedure is less complex and leaves minimal to no scar at all. Additional cushion can be added at pubic bone to correct fat loss. It also mask the minor hypertrophy of the labia minora, as well as improves the skin sagging of the vulvar area. Conclusions. The patient is instructed to refrain from sexual activities for 5-6 weeks.The minimal complications that are noted include hematoma and tolerable pain that are addressed with proper medications.

Keywords: fat graft, fat transfer, lipotransfer, autologous fat transfer, platelet rich plasma

 

 

 

The psychological impact of COVID-19 pandemic: a comparison between urological
and obstetrics-gynecology healthcare workers

 

Alida Puia-Dumitrescu¹, Orsolya Mártha^2,3, Simona-Alexandra Pascal⁴, G. Ráduly^5,6, Alexandra Cozlea¹

1. Department of Obstetrics and Gynecology, Emergency County Clinical Hospital of Târgu-Mureș, Romania

2. Department of Urology, Mureş County Clinical Hospital, Târgu-Mureș, Romania

3. Department of Urology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu-Mureș, Romania

4. Department of Psychology, University of Bucharest, Romania

5. Department of Anaesthesiology and Intensive Care, Emergency County Clinical Hospital of Târgu-Mureș, Romania

6. Department of Anatomy and Embryology, “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology, Târgu-Mureș, Romania

 

Introduction/objectives. Recent studies raise concerns about the high psychosocial impact of the COVID-19 outbreak among frontline healthcare workers. The purpose of this study is to evaluate the state of mental health amidst employees of the Mureș County Clinical Hospital, Clinic of Urology and Clinic of Obstetrics-Gynecology. Methodology. The psychological distress caused by the pandemic and its impact were assessed considering the fear of COVID-19 and the reaction to stress, using a 21-item questionnaire. The study groups were formed as follows: (1) 105 workers from the Urology Clinic; (2) 103 workers from the Obstetrics-Gynecology Clinic, with ages between 23 and 64 years old (M=42.43, SD=10.56), surveyed in May-June 2020. Results. The results emphasized differences between the two groups regarding fear of COVID-19 (t=2.61; p=0.010); perception of stress level (t=3.48; p<0.001); fear of danger at work (t=4.10; p=0.001); fear of going to work (t=2.71; p=0.007); fear of going home (t=4.67; p=0.008); avoidance from family members (t=2.86; p=0.005); perception of protection (t=-3.97; p<0.001); perception of rest time (t=-3.91; p<0.001). The following significant relations with fear of danger at work were found: fear of COVID-19 (r=0.59); MPQ (r=0.58); perception of stress level (r=0.54); fear of going to work (r=0.62), fear of going home (r=0.62). Conclusions. Training and preparation for future epidemics or disasters are strongly recommended.

Keywords: fear of COVID-19, urology, obstetrics-gynecology, psychosocial impact, stress reaction

 

 

 

Complications in female cosmetic genital surgery

 

Dawid Serafin

Serafin Clinic, Gliwice, Poland

 

Introduction. This presentation highlights the possible complications during procedures in the field of plastic and reconstructive gynecology, due to the selection of incorrect anaesthesia, inappropriate technique or to unsuitable sewing. Methodology. This is a case report. During the presentation, there will be shown some possible ways of dealing with the complications that occur. Results. The photographic case documentation will show the possible techniques of repairing the damage after labial hypertrophy reductions and the techniques of correcting the most common complications. Conclusions. The most common complication is wound dehiscence of the postoperative wound, and the physician will need a specific techique in order to manage this correctly.

Keywords: botched labiaplasty, sewing technique, extended posterior wedge labiaplasty, labial hypertrophy

 

 

 

Abdominal sacropexy incidents and distant results

 

Mihaela Camelia Tîrnovanu¹, Cerasela Mucileniţa², Roxana Corduneanu², Alexandra Iov³, Vlad Gabriel Tîrnovanu³, Demetra Socolov¹

1. “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

2. “Cuza Vodă” Clinical Hospital of Obstetrics and Gynecology, Iaşi, Romania

3. MD student, “Grigore T. Popa” University of Medicine and Pharmacy, Iaşi, Romania

 

Sacropexy is the gold standard surgery for the management of apical genital prolapse, registering a high success rate for anatomical correction. Objective. We aimed to evaluate the intraoperative incidents and the remote results regarding sacropexy. Materials and method. The prospective study was carried out between April 2012 and August 2018, and included 156 cases. We have performed abdominal sacropexy with three attachment point varieties of the mesh: vaginal cuff, cervical cuff, and cervix in cases with uterus preservation. Results. The mean patient age was 66.69±6.4 years old (39-81 years old). The intraoperative incidents were difficult posterior detachment of the peritoneum due to endometriosis or chronic inflammation – 15 cases, low aortic bifurcation with reduced attachment area to the presacral space – 24 cases, thin presacral ligament – 7 cases, presacral bleeding – 20 cases, and ureter near the margin of the presacral peritoneal breach. The immediate postoperative complications included: one occlusion after four days (epigastric hernia), one case of subperitoneal vaginal cuff hematoma, and one patient with mesh externalization one month after surgery, following sexual intercourse. Out of 31 patients with preoperative stress incontinence, 14 had a simultaneous suburethral sling surgery with sacropexy. Three cases needed subsequent suburethral sling fixation. Remote results: one case of deep posterior pain, a 73-year-old patient with mesh erosion, and three cases at 6 and 12 months with central anterior compartment prolapse. Conclusions. The preoperative patient counseling is important. The possibility of erosion caused by the mesh and the anatomical failure over time are not confirmed by this study. We observed three relapse cases – anterior compartment prolapse. We suggest postponing the procedure for urinary incontinence.

Keywords: sacropexy, abdominal sacropexy, genital prolapse