[Again about the drug induced abortion]

Medical abortion is known as a non-aspiration or non-surgical abortion for terminating an unwanted pregnancy up to 63 days' gestation. It is not officially regulated in Bulgaria.

High levels of women's satisfaction and compliance with transdermal contraception: results from a European multinational, 6-month study

OBJECTIVE

To investigate compliance, satisfaction, and preference in women using a transdermal contraceptive patch.

METHODS

Women (18-46 years) from eight European countries used contraceptive patches (norelgestromin 6 mg, ethinylestradiol 600 μg) for six, 4-week treatment cycles. Compliance, satisfaction, and preference were assessed after 3 and 6 cycles and study completion using self-report methods.

RESULTS

Of the 778 participants, 36.8% (n = 287) used no contraception at baseline. The most common methods were oral contraceptives (67.9%, n = 334) and barrier methods (21.5%, n = 106). Of oral contraception users, 63.5% (n = 212) were satisfied or very satisfied with their previous method, but compliance was poor with 77.8% (n = 260) reporting missed doses. After 3 and 6 cycles, >80% of all included women were satisfied or very satisfied with the patch. At study completion, most participants (73.7%) reported a preference for the patch compared to their previous method. Of 4107 cycles, 3718 (90.5%) were completed with perfect compliance. Two pregnancies occurred during this study, representing a Pearl Index of 0.63. No new safety issues were identified and the patch was well tolerated.

CONCLUSION

Women were highly satisfied with transdermal contraception and preferred this form of family planning over their previous method. Transdermal contraception represents a valuable addition to contraceptive options with potential to offer high compliance and efficacy.

[Solifenacin in treatment of the overactive bladder syndrome--diagnosis, clinical management and results]

The overactive bladder syndrome (OAB) is a pathological condition that affects millions of people round the world. Its incidence increases with ageing. The main therapeutic option for OAB nowadays is anti-muscarinic drug therapy.

AIM

To define and implement the diagnostic criteria, clinical guidelines in our country and to evaluate the results of Solifenacin therapy in patients with OAB.

MATERIAL AND METHODS

Along a three years period (2006-2009) 163 OAB patients were analyzed followed and treated. In our group of patients 106 (65.2%) are females and 57 (34.8%)--males. The diagnosis is based mainly on the complaints of the patient, evaluated thoroughly with a detail anamnesis and questionnaires. Urodynamic studies were performed In some of the patients. The efficacy of Solifenacin therapy has been validated with the same methods used in SUNRISE and VENUS studies.

RESULTS AND DISCUSSION

The mean age of female patients in our group is 63.8 years, and 65.6 years for males. The most commonly observed symptoms of OAB are urgency--88.3% and frequency--92%. Urge-incontinence is observed in 48.8% of the cases. Therapy with Solifenacin 5 and 10 mg has alleviated urgency in 82% and urge-incontinence in 88.9%. Mean number of pads used for 24 hours has decreased from 2.6 to 0.4 after therapy.

CONCLUSION

Urgency is the main mandatory symptom for the diagnosis OAB. Therapy with Solifenacin 5 and 10 mg guarantees very good clinical results, and high degree of compliance of the patients.

[Therapeutic approach in pregnant women with an autoimmune thrombocytopenic purpura]

The case presented herein aim to update the existing information about the common diagnostic problems and therapeutic approach in pregnant women that have autoimmune thrombocytopenic purpura (ATP).

[Autoimmune thrombocitopenic purpura in pregnancy]

The author deals with haematologists' and obstetricians' current views on acquired ATP in children and adults, characterised by a transient, acute or chronic decrease in platelets count (<50.109/l) due to premature destruction by the reticuloendothelial system. The most common questions arising in connection with this disease are: what is autoimmune thrombocytopenic purpura; is there any correlation between pregnancy and ATP; what are its symptoms; does pregnancy itself affect the autoimmune disease. If is of utter importance for women with ATP to be aware of the risks these symptoms pose both on the health of the mother and the foetus. Obstetricians and gynaecologists seldom object to pregnancy in women with ATP. Nevertheless, it is essential to point out that additional monitoring and therapy are needed. There is no medical evidence that supports the notion of terminating pregnancy due to ATP. Assessment is made only by an obstetrician, haematologist and pediatrician working in close collaboration. This collaborative work must be present throughout the whole pregnancy, delivery and puerperium. The treatment necessary for women with ATP aims to establish platelet count over 50.000 ppm when approaching the end of pregnancy, preferably between 80.000 ppm - 100.000 ppm taking into account vagina or surgical delivery as well as the administration of anaesthetic. Delivery management must be decided entirely on obstetrics consideration, but not on ATP ones. Pregnant women with ATP must be monitored and treated with caution by a highly specialised medical team.

[Autoimmune thrombocytopenia during pregnancy (case report and review of literature)]

A case of autoimmune thrombocytopenia [AIT], diagnosed in the first trimester of pregnancy is described. Despite the active treatment with steroids and IVIG the platelet count dropped to extremely low levels in the third trimester--8 x 10(9)/l. Labor was induced in 34 w.g. because of the ineffective treatment of AIT, clinical and sonographic evidence of IUGR and favorable pelvic score. Before and during labor induction platelets were transfused and recombinant factor VIIa (rFVIIa) was applied. After delivery antifibrinolytics as well as low molecular weight heparin [LMWH] were applied also. Laboratory tests demonstrated transient fibrinolysis activation after delivery. Mild transient thrombocytopenia of the newborn was found that was successfully treated with steroids. Review of contemporary literature is made with analysis of the therapeutic approaches in cases of AIT during pregnancy. The impact of thrombocytopenia on pregnancy, labor and delivery, the fetus and the newborn and the route of delivery are discussed. The clinical course and the therapeutic strategies in the particular case are analyzed. A nouvelle approach during labor and after delivery was the application of rFVIIa (because of the tendency for elevation of the titers of allogenic antibodies due to platelet transfusions) and of antifibrinolytics (preserving platelet functions).

[Changes of activation in T-lymphocyte subpopulations in peripheral blood during pregnancy]

From an immunological point of view during pregnancy the interactions between the steroid sex hormones and immunocompetent cells as a part of the dynamic local and peripheral immune response is of a particular interest. The aim of our study is to investigate the expression of the early activation marker CD69 in T-lymphocytes subpopulation: CD4+ and CD8+ in peripheral blood from pregnant and non-pregnant women. Our data clearly demonstrate an increase of the percentage of activated CD4+ lymphocytes in pregnant women in comparison to non-pregnant and this difference is statistically significant. A similar but not statistically significant dependency is observed in CD8+ and CD69+ lymphocytes. From the obtained results we conclude that during pregnancy the activation of CD4+ lymphocytes is increased, which probably leads to an increased production of cytokines that shifts the immune response to Th2 type which is protective for pregnancy. This could be partly due to the increased levels of progesterone.

[Hormonal treatment of recurrent spontaneous abortions]

A retrospective study with 79 pregnant women was conducted. All of them were diagnosed as spontaneous abortion. The patients were separated in two group and the women have been treated in two schemes--51%--Utrogestan and 49%--Utrogestan and Profasi. The medication was applied only into the first trimester of the pregnancy. The duration of the therapy was 15.0 +/- 12.34 days. The mean gestational age in this study was 7.6 +/- 3.0 gestational weeks. Women with a first pregnancy and spontaneous abortion were excluded from the study. The number of this hormonal treated pregnancy was 2.84 +/- 1.13. 10.2% of the followed women had 3 and more than 3 miscarriages. The followed group of women was historically and clinically heterogenic. For that reason we think that many other factors could play a role in the optimum outcome of this pregnancy. The criteria for positive result we accepted the vital embryo/fetus on the time of dehospitalization. From these pregnancy only 3 terminated with miscarriage--3.79%. The rest of 96.2% went at home with intact pregnancy. The authors try to find a theoretical support for use of micronized progesterone Utrogestan--there could be some changes in the cellular and humoral immunity at repeated abortions, related to the change of the cytokine production. It could be find an ability to realize a readjustment of the endocrine system of the mother and to control the immune reaction in the fetoplacental unit.

[Increased nuchal translucency at 11-14 weeks of gestation in congenital heart disease, genetic syndromes and adverse pregnancy outcome]

Nuchal translucency (NT) measurement between 11-14 weeks of gestation is an'effective method of ultrasound screening for chromosomal fetal anomalies, congenital heart disease, some other structural abnormalities, rare genetic syndromes, skeletal dysplasia and adverse pregnancy outcome (spontaneous abortion and intrauterine fetal demise). The aim of the present study is to assess the prognostic value of increased first trimester NT in fetuses with normal karyotype in relation to pregnancy outcome.

[Localization of leiomyoma with respect to the placenta--factor for complications during pregnancy?]

We are presenting two cases of pregnant women with leiomyoma of the uterus, diagnosed antepartum. In both cases the patients were admitted on an emergency basis due to premature uterine contractions. In both cases preterm hemorrhage and fetal malpresentations were observed. The complications of pregnancy in both of the cases were primarily based on the location of the leiomyoma with respect to the placenta--intramural or submucosal disposition of the leiomyoma, retroplacentarily situated.

[First trimester nuchal translucency thickness in normal fetuses in the Bulgarian population]

Nuchal translucency (NT) measurement between 11-14 weeks of gestation is an effective method of ultrasound screening for chromosomal fetal anomalies. The aim of the present study is to construct normal reference ranges of NT thickness for the Bulgarian population. The choice of cut-off NT thickness above which an invasive procedure should be offered is discussed.

[Impact of inherited thrombophilia on the development of some pregnancy complications]

AIM

To assess the clinical significance of inherited thrombophilia [IT] for the development of some pregnancy complications.

MATERIAL AND METHODS

The incidence of the following factors was studied in 97 pregnant women with pregnancy complications and in 103 controls: R506Q mutation encoding Factor V Leiden [FVL] synthesis, Prothrombin G20210A mutation, T677 methylenetetrahydropholate reductase mutation [MTHFR], 4G/4G polymorphism of the plasminogen activator inhibitor [PAI 4G/4G]. Among 97 patients in the group studied 39 had early onset severe preeclampsia [PE], 14--placental abruption [AP] without PE, 18--intrauterine growth restriction [IUGR] without PE, 12--stillbirth [SB] without PE, 14--habitual spontaneous abortions [HSA]. The control group included 103 clinically healthy pregnant women with at least one previous uneventful pregnancy, without history of thromboembolic disorders. In addition, patients with severe PE with and without IT were compared regarding g. a. and birthweight at delivery and intrauterine fetal loss rate. DNA analysis was performed according to internationally accepted standards. Pregnancy outcomes were ascertained from hospital records. Statistical significance (p < 0.05) was assessed by means of Student's t-test.

RESULTS

FVL mutation was found in 23.7% (23/97) of the patients from the studied group and in 5.8% (6/103) of the controls. Prothrombin G20210A carriers were 11% (11/97) of the studied and 3.8% (4/103) of the controls, while with PAI 4G/4G polymorphism they were 30.9% (30/97) and 14.5% (15/103) respectively. MTHFR T677 was not more frequent in the studied group (8.2%) compared to the control one (29%). Eight of the patients (9.6%) were carriers of more than one mutation. In 22 cases with early onset severe PE and IT gestational age and birthweight at delivery were lower than in the cases with severe PE without IT while intrauterine fetal loss rate did not differ significantly between the two groups.

CONCLUSIONS

Inherited thrombophilia is found more frequently in women with pregnancy complications like PE, IUGR, AP, SB, HSA. The incidence of homozygous MTHFR T677 is not higher in these cases. IT worsens the prognosis of severe PE. The diagnosis of IT is important since anithrombotic therapy has to be considered to protect the mother and the fetus.

[Ultrasound screening for Down syndrome and other chromosomal abnormalities by fetal nuchal translucency measurement between 11-14 weeks of gestation]

AIM

To assess the feasibility of nuchal translucency [NT] measurement as a screening tool for Down syndrome [DS] and other chromosomal anomalies [ChA] between 11-14 weeks of gestation [w.g.].

MATERIALS AND METHODS

A longitudinal prospective follow up study was carried out at a tertiary referral center including 408 singleton pregnancies between 11+0 and 14+0 w.g. Three experienced sonographers performed transabdominal and/or transvaginal scans using high-resolution ultrasound equipment. The ultrasound examinations included assessment of fetal number and viability, NT measurement and fetal anatomy survey. Down syndrome [DS] risk was calculated using the specialized computer program provided by the Fetal Medicine Foundation [FMF], UK. In cases of estimated DS risk > or = 1:300 invasive prenatal diagnosis was offered--chorionic villus sampling [CVS] between 11-14 w.g. or amniocentesis [AC] after 15 w. g., as well as follow-up scans including fetal echocardiography. The samples were tested by cytogenetic analysis, DNA analysis and/or FISH. When chromosomal fetal abnormality was detected termination of pregnancy was an option. Pregnancy outcome was ascertained from hospital records, referring physicians or the patients themselves.

RESULTS

108 (26%) out of the 408 women were ?35 years and 300 (74%)--below that age. A total number of 9 fetal chromosomal anomalies [ChA] were found including 6 cases with DS, 2--with trisomy 18 [T18] and 1--with Turner syndrome. The overall sensitivity for DS was 66.7% for a false-positive rate [FPR] of 13.4%. The figures for all ChA were 77.7% and 12.8%, respectively. All three cases of ChA other than DS were in the screen-positive group. The overall sensitivity and FPR for ChA for patients > or = 35 years was 80% and 35%, while for patients < 35 years it was 75% and 5.1 %, respectively. Diagnostic invasive procedures were performed in 50 out of 58 screen-positive cases, including 7 of the cases with ChA. In all 7 cases with prenatal diagnosis of fetal ChA the parents chose to terminate the pregnancy.

CONCLUSIONS

First trimester DS screening by NT measurement has high sensitivity and specificity. Screening for other chromosomal abnormalities missed by second trimester biochemical serum tests is also possible. Invasive prenatal diagnosis is performed at an early gestational age when termination of affected pregnancies by D&C is still an option. Other important advantages are the possibility of screening for ChA in multiple gestations, as well as early diagnosis of major fetal anomalies.

[Attitude of pregnant women towards prenatal screening for chromosomal and structural fetal anomalies between 11-14 weeks of gestation]

AIM

The aim of the present survey is to analyze the attitude of pregnant women towards the possibilities of prenatal screening and diagnosis between 11-14 weeks of gestation (w.g.).

MATERIAL AND METHODS

Overall 109 pregnant women, hospitalized in SBALAG "Maichin dom", received written information about the possibilities for prenatal screening and diagnosis between 11-14 w.g. and 16-20 w.g., as well as a comprehensive description of the potential advantages and disadvantages of the different approaches/methods of screening/diagnosis. Consequently, the patients were asked to answer 13 closed and semi-closed questions in an anonymous enquiry.

RESULTS

Overall 97,2% (106/109) of the women agreed to perform an ultrasound examination for fetal nuchal translucency measurement as a screening tool for chromosomal anomalies between 11-14 w.g. Furthermore, 82,6% (90/109) preferred the option of first trimester biochemical screening, rather than screening in the second trimester. On the other hand only 62,4% (68/109) accepted chorionic villous sampling between 11-14 w.g. in comparison to 83,5% (91/109) who agreed to perform an amniocentesis between 16-20 w.g.

CONCLUSION

The vast majority of women prefer prenatal screening programs to be scheduled in the first, rather than in the second trimester. However, most women would still choose for a relatively safer second trimester invasive procedure instead of the option of earlier prenatal diagnosis.

[Antiphospholipid syndrome and pregnancy]

The antiphospholipid antibody syndrome (APLS) is multisystem, autoimmune disease, which is characterized by: thrombosis, obstetrics complications and thrombocytopenia. The two most clinically significant antiphospholipid antibodies (APLa) that are associated with recurrent pregnancy loss and thrombosis are anticardiolipin antibodies (ACL) and lupus anticoagulant (LA). The laboratory diagnosis is based on the presence of moderate to high positive ACL and/or LA. The inhibitory effect of antiphospholipid antibodies /APLa/ on trophoblast intercellular fusion, hormone production and invasion may cause pregnancy loss. Once placentation is established their thrombogenic action leads to decreased placental perfusion and subsequent infarction. The APLa--mediated inhibition of trophoblastic invasion and APLa--mediated vasculopathy in the placental bed arteries result in abnormal uterine artery /UA/ Doppler waveforms. The association between APLa and high resistance index /RI/ and/or diastolic notch /DN/ in the Doppler waveforms is high predictive for adverse pregnancy outcome, including pre-eclampsia/eclampsia, intrauterine growth retardation, placental abruption, intrauterine fetal death. Maternal treatment and careful monitoring of fetal well-being are mandatory in the management of these high-risk pregnancies.

[Sucessful pregnancy outcome following three severe placental abruptions and intrauterine fetal death in the patient--heterozygous carrier of R506Q mutation of factor V (Leiden)]

A case of successful pregnancy outcome is reported in a patient with 3 preceding severe placental abruptions with intrauterine fetal death and caesarean deliveries. In the course of the current pregnancy heterozygosity for R506Q mutation of factor V (Leiden) was diagnosed in 26 weeks of gestation [w.g.] and low molecular weight heparin [LMWH] therapy initiated. Maternal condition was stable until delivery and all laboratory findings were within normal range. The fetus was followed up by ultrasound biometry and Doppler blood flow studies. From 28 w.g. on NST and biophysical profile were included. An emergency caesarean section was performed in 34 w.g. because of contractions not responding to tocolysis. The newborn was in good condition with weight and length corresponding to the 10th centile for gestational age [g.a]. Histologic study of the placenta showed anemic infarctions and recent haemorrhages in the basal and the chorionic plate. The initiation of LMWH therapy in the case reported was late (26 w.g.). By that moment there was already evidence of impaired fetal growth with fetal biometry corresponding to the 10th centile for g.a. After LMWH therapy was started no further slow down of fetal growth was registered. Successful pregnancy outcome may be related not only to LMWH therapy but also to other factors like active fetal monitoring after 28 w.g. and the emergency caesarian delivery immediately after the onset of uterine contractions. Patients with past obstetric history of severe preeclampsia, placental abruption or fetal growth restriction have to be screened for hereditary or acquired thrombophilia. If a thrombophillic state is present early LMWH therapy has to be considered. It is aimed to prevent anaemic placental infarctions and thrombotic complications.

[Pentalogy of Cantrell associated with increased nuchal translucency at 12+1 w.g]

Pentalogy of Cantrell is a rare sporadic syndrome with unknown etiology including five major system organ malformations. We present a case of pentalogy of Cantrell associated with increased nuchal translucency [NT] which was diagnosed at 12+1 weeks of gestation [w.g]. Termination of pregnancy was performed at 12+3 w.g.

[Screening for chromosomal anomalies of the fetus between 11-14 gestational weeks. Review of literature]

The aim of the review is to provide an up-to-date overview of the possibilities for prenatal screening for chromosomal fetal anomalies between 11-14 weeks of gestation. A specific ultrasound marker in the first trimester, known as fetal nuchal transluceny [NT], is described. The usefulness of fetal NT as a screening tool for chromosomal anomalies, some structural anomalies, rare genetic syndromes and adverse pregnancy outcome is discussed.

[First trimester ultrasound screening for structural and chromosomal anomalies in multiple pregnancy]

AIM OF THE STUDY

To assess the feasibility of first trimester ultrasound screening for structural and chromosomal fetal anomalies in multiple gestations.

METHODS

An observational prospective follow up study was carried out in 32 cases of multiple pregnancies. Two scans were scheduled in each case--the first, between 6-9 weeks of gestation (w.g.) and the second, between 11-14 w.g. The aim was assessment of fetal number, viability, chorionicity/amnionicity and fetal biometry. In addition, nuchal translucency [NT] measurement, assessment of risk for chromosomal anomalies and fetal anatomy survey were always performed. Increased NT > or = 95 percentile and/or detection of structural anomaly were considered indications for invasive prenatal diagnosis and fetal karyotyping. Selective fetocide was considered in cases of chromosomal or structural anomalies and in high-order multiple gestations (> or = 3 fetuses). Pregnancy outcome was ascertained by the physical examination of the fetuses, placentas and membranes postpartum, the hospital records, the referring physicians or the parents.

RESULTS

From 32 cases of multiple pregnancies included in the study, 28 were twins, and 4--triplets. 68% (19/28) of the twin pregnancies were bichorionic-biamniotic [Bi-Bi], 25% (7/28)--monochorionic-biamniotic [Mo-Bi] and 7% (2/28)--monochorionic-monoamniotic [Mo-Mo]. 4 cases of increased NT in one of the twins (1--associated with trisomy 21) were observed, as well as 2 cases of structural fetal anomalies (1--discordant for exencephaly, and 1--with conjoint twins), 2 cases of feto-fetal transfusion syndrome that developed in the second trimester (1--associated with increased NT between 11-14 w.g.), 1 case of TRAP syndrome [twin-reversed arterial perfusion] and 1 case of cord entanglement in monoamniotic twins. In addition, there were 4 cases of a vanishing twin in the first trimester, and in 2 other cases spontaneous miscarriage of both twins occurred before 24 w.g. In two of the triplet pregnancies selective fetocide was performed, one was successfully delivered at 33 w.g. and in the last case the parents chose to terminate the pregnancy.

CONCLUSIONS

First trimester ultrasound is a method of choice for detection of major structural fetal anomalies in multiple gestations. Increased NT between 11-14 w.g. in multiple pregnancies is a useful screening tool for detection of chromosomal fetal anomalies, while in monochorionic twins its presence might predict the development of fetofetal transfusion syndrome. First trimester selective fetocide in high-order multiple gestations or in affected twins is one of the options in pregnancy management.

[Ultrasound screening and diagnosis of fetal structural abnormalities between 11-14 gestational weeks]

AIM OF THE STUDY

To assess the feasibility of ultrasound screening and diagnosis of structural fetal anomalies at the 11-14 week scan.

METHODS

An observational prospective follow up study from March 2000 till May 2003 was performed at three referral centers by seven experienced sonographers with high-resolution ultrasound equipment. 1135 singleton pregnancies between 11+0 and 14+6 weeks gestation (w.g.) participated in the study. The first trimester scan included assessment of fetal number, viability and biometry, nuchal translucency [NT] measurement and fetal anatomy survey performed according to standardized published protocols. Increased NT > or = 95th centile and/or diagnosis of structural fetal anomaly was considered as indication for invasive prenatal diagnosis, early fetal echocardiogram and follow-up scans, including a detailed fetal anomaly scan at 18-22 w.g. and a third scan at 28-32 w.g. Pregnancy outcome was ascertained from hospital records, referring physicians or the patients themselves.

RESULTS

The overall prevalence of structural fetal anomalies in the present study was 4.6% (53/1135). 22% (12/53) of the structural anomalies were detected between 11-14 w.g. 9 of those had normal karyotype, and 3 were associated with chromosomal anomalies. Furthermore, 10 cases of increased NT, with or without non-immune hydrops fetalis, were associated with congenital heart disease, rare genetic syndromes and adverse pregnancy outcome later in gestation. The ultrasound detection rate of structural fetal anomalies in the present study increased from 22% (12/53), to 69% (37/53) and 79% (42/53) for the first trimester scan, the first and second trimester scans, and the combination of all three scans, respectively. 21% (11/53) of all structural fetal anomalies were missed by prenatal ultrasound.

CONCLUSIONS

The first trimester scan is a method of choice for the diagnosis of major structural fetal anomalies. NT measurement is a useful screening test for chromosomal anomalies. In cases with increased NT subsequent development of congenital heart disease, rare genetic syndromes or adverse pregnancy outcome should be ruled out. At present, the second trimester scan constitutes an indispensable tool for the detection of most structural abnormalities. Even in advanced gestation the prenatal diagnosis of certain anomalies is difficult and often unfeasible.

[Emergency contraception with levonorgestrel for teenagers--efficacy, tolerability, and level of information awareness]

OBJECTIVE

Assessment of efficacy and side effects of emergency contraception for teenagers with levonorgestrel (LNG) and the level of users' informedness about possibilities and practical application.

METHODS

The subjects are healthy girls (n = 49) with regular menstrual cycles at the age between 15 and 19, having had one unprotected or faultily protected sexual intercourse. All of them have administered 0.75 mg LNG within the 72nd hour, repeated after 12 hours. The data have been processed by variational analysis.

RESULTS

One pregnancy was registered of a girl with firstintake at the 67th hour - pregnancy rate - 2,0%. The most frequent side effect was nausea - 26,5%, folowed by breast tenderness - 22,4% and fatigue - 20,4%. An up to 7th day delay in menstrual cycle is non significantly more frequent - 14,3%, followed by a delay of more than 7 days breakthrough bleeding - 8,2%. No significant changes were established in the lenght of the menstrual cycle. Emergency contraception is sought for after unprotected sexual intercourse in 69,4%, and condom failure problems in 30,6%. Only 18,4% have sufficient information about the possibilities and practical use of emergency contraception.

CONCLUSION

LNG provides effective, highly tolerable contraception with a small number of side effects. Need is felt for serious popularization of the application of emergency contraception with teenagers.

[Pregnancy complications with abnormal results of biochemical screening for Down syndrome in second trimester and normal fetal karyotype]

Pregnancy complications were studied in the following groups of pregnancies with structurally and chromosomally normal fetuses: 1) 216--with elevated free beta-hCG above 2 MoM and 134--above 2.5 MoM; 2) 37--with elevated alpha-fetoprotein [AFP] above 2 MoM; 3) 67 screen-positive patients below the age of 35. The following complications were compared in the studied and the control groups: preterm delivery and premature rupture of membranes [PROM], preeclampsia (in general and severe one), IUGR without preeclampsia, delivery of small for gestational age [SGA] and low birth weight [LBW] infants and perinatal fetal loss. Pregnancy outcome in cases with free beta-hCG above 2 MoM was not different from that in the control group. With 2.5 cut-off level the incidence of preeclampsia and of LBW infants was higher in the studied than in the control group. Elevated AFP above 2 MoM alone was associated with more frequent preeclampsia including severe one (in all the latter cases--IUGR present). In the screen-positive group the incidence of preeclampsia (in general and severe one with IUGR), SGA and LBW infants and perinatal mortality rate were significantly higher than in the control group. No difference was found between the studied and the control groups regarding subsequent development of IUGR without preeclampsia, preterm delivery and PROM. Abnormal second trimester serum screening test results (elevated free beta-hCG or AFP alone above 2.5 and 2 MoM respectively) in pregnancies with normal fetal karyotype indicate higher risk for subsequent development of preeclampsia. Screen-positive patients, being a heterogeneous group (including ones with elevated free bb-hCG alone and ones with elevated both free beta-hCG and AFP), are at increased risk for other pregnancy complications too.

[Second trimester Down syndrome serum screening--results from a pilot study]

The results from a pilot prospective study--second trimester Down syndrome [DS] serum screening between 15 and 21 w.g. with two markers (alpha-fetoprotein and free bb-hCG)--were summarised. Sensitivity, false-positive rate [FPR], positive predictive value [PPV] of the screen positive and negative predictive value [NPV] of the screen negative result for the sbgroups II and below 35 years of age were analysed. The uptake for invasive prenatal testing in screen positive patients and the percentage of terminated pregnancies with prenatally diagnosed DS fetuses as well as the ratio "lost unaffected pregnancies/1 DS fetus diagnosed antenatally" were also calculated. High sensitivity of the DS serum screening was achieved--75% and 87.5% in the subgroups below and II the age of 35 respectively with 6.6 and 31.7% FPR. With higher DS age risk the PPV of the screen positive test was higher and the NPV of the screen negative result--lower. The percentage of invasive prenatal testing in screen positive patients was high (average 83.4%) without significant differences in the two age subgroups. Pregnancy was terminated in all cases with antenatally diagnosed DS fetuses. The ratio "lost unaffected pregnancies/1 DS fetus diagnosed antenatally" for serum screening was lower compared to the same ratio when screening by age. The results from our pilot study (serum screening sensitivity and FPR, uptake for invasive testing in screen-positive cases) are comparable to the ones reported in literature. This is an important prerequisite for introduction of mass DS screening for our population.

[Second trimester pregnancy termination with and without prostaglandins]

The effectiveness of three methods for second trimester pregnancy termination [TOP) was compared. A retrospective analysis was made in 34 cases with TOP by intraamniotic saline instillation and 19 cases with extra-amniotic appreciation of y ballon-catheter, followed by stimulation of uterine contractions by intravenous oxytocin infusion. The results were compared with the ones in 13 prospectively studied cases in which the extra-amniotic appreciation of the ballon-catheter was preceded by treatment of the cervix with 0.5 mg prostin E2 intracervically. In nulliparous patients the treatment of the cervix with y single dose prostaglandins did not shorten the mean abortion time neither reduced the percentage of unsuccessful and prolonged abortions. In parous patients the abortion time was significantly reduced. No failed or prolonged abortions were registered.

[Administration of exogenous surfactant in premature very low birth weight infants with RDS]

A retrospective study is carried out with the aim of establishing the effect from surfactant therapy on pulmonary function, survival and complication from intensive therapy on VLBWI with RDS. 67 premature infants below 1500 grams are included in the study divided in 3 groups: I gr.--27 babies treated with Corosurf; II gr.--16 babies treated with Exosurf; III gr.--24 control babies without surfactant. The results show that in spite of relatively lower gestational age and higher incidence of inborn infection in group I, Curosurf treated babies spend shortest time on mechanical ventilation and oxygen therapy showing lower incidence of BPD, IVH and mortality rate.

[Frequency of antiphospholipid antibodies and Leiden mutation of hemostasis Factor V in unexplained recurrent fetal and embryo loss]

Object of the study are women with a history of unexplained recurrent embryo, fetal and early neonatal death, severe preeclampsia, fetal growth retardation, abruptio placentae, puerperal thromboses. Quite often placental insufficiency is linked to abnormal vascular system and hemostatic disturbancies. In about 65% of the women with a complicated and in 18% of the women with a normal pregnancy are observed different genetic anomalies that lead to a hypercoagulative state. A major place is taken by the Leiden mutation of hemostasis factor V, by protein C and protein S deficiency, etc. Another disease that leads to arterial and venous thromboses and is most often linked to recurrent miscarriage is the antiphospholipid syndrome. Many authors confirm the findings of large placental infarctions and thromboses in women who are positive for antophospholipid antibodies.

[Asymptomatic infections of the genital tract and infertility]

Diagnosis of male genital tract inflammations plays a significant role in andrology. Although genital infections are often silent they can severely impair male infertility. In seminal plasma of 100 patients were determined IgG and SigA (radial immunodiffusion) the number of peroxydase-positive cells in addition to conventional semen parameters and microbiological investigations. There was carried out quantitative determination of alpha-amylase in connection with semen liquefaction. The results showed that exact quantitation of above mentioned parameters distinguish inflammatory male adnexal affections, which is appropriate for control of anti-inflammatory treatment and facilitates the diagnosis of inflammatory process in andrology.

[The attitude of pregnant women to the possibilities for the prenatal screening and diagnosis of Down's syndrome in the 2nd trimester]

The aim of the study was to assess pregnant women's attitude and receptivity for second trimester prenatal screening and diagnostic tests for fetal Down syndrome [DS], factors that influence attitude formation, sufficiency of patients' information, advisability of introduction of these tests in routine prenatal care Interviews with 129 pregnant women were conducted after they had received written information concerning prenatal DS screening and diagnostic tests Five questions to the point of the matter as well as 14 related to the personal characteristics of the interviewed were included. Ultrasound screening rt]. accepted by 98.4% serum screening--by 93% and invasive prenatal testing--by 90% of the pregnant women Patients receptivity for serum screening and invasive testing Was influenced by factors like age, past obstetric history educational level, religiosity, attitude towards patient's own health For some of the factors statistically significant relationships were present while for others only some trends were outlined Regarding patients' high receptivity for prenatal DS screening and diagnostic tests the latter can be recommended as an element of the routine prenatal care in our country.

[The preoperative preparation of the vagina with Betadine before abortion on demand]

Recent evidence has associated bacterial vaginosis and trichomoniasis with several postoperative complications. We carried out a prospective study aiming to estimate the frequency of vaginitis in women wanting to make an artificial abortion and the possibility to influence this infections by local application of vaginal BETADINE suppositories in all forms of infectious vaginitis: Candida albicans, trichomonas vaginalis and bacterial vaginosis.

[Modern noninvasive methods for terminating pregnancy in the 2nd trimester]

Pregnancy interruption upon medical indications between the 13th and 21st gestational weeks is carried out mainly by two-phase invasive techniques including intraamnial application of NaCl and vaginally prostaglandins, laminarie or solutio rivanoli, followed by a surgical treatment (instrumental revision). Because of its invasive character these techniques can cause severe complications. The application of prostaglandin analogues (P.G.) is safer but it is connected with gastrointestinal side effects and their action is often protrachirated especially "primigravida" with a undeveloped infantile P.V.C.U. the author proposes a highly effective non-invasive technique implementing the following combination: sensibilization with an antiprogestin (synthetic norsteroid--Ru 486), applied perorally: 1 tablet 200 mg; 24 hours before the intracervical (vaginal) insertion of the PGO2 tablet or gel. Results are extremely effective and good: the time for pregnancy interruption is reduced to more than 50% (average 5 to 10 hours), side effects and complications are minimized and the hospital stay is significantly reduced.

[Application of low-molecular-weight heparin during pregnancy and delivery in case of reproductive failure due to antiphospholipid syndrome]

The authors report the results of application of low molecular weight heparin during pregnancy, delivery and after birth to counter placental insufficiency in case of primary antiphospholipid syndrome. The patient had been treated with Fraxiparin for 126 days. No systemic or local side effects were spotted. There were no genital bleeding and tromboembolic accidents during pregnancy. A Caesaerean section was carried out under spinal anaesthesia. Fraxiparin treatment was not halted during the section, which was accompanied by a normal blood loss. The pregnancy yielded an eutrophic newborn and no complications were demonstrated during the neonatal period.

[The use of Curosurf with premature infants--the prevention or treatment of the neonatal RDS]

A randomized clinical prospective study is carried out aiming to compare prophylaxis with Curosurf versus rescue treatment. 28 inborn VLBW I are included: 17 received Curosurf as prophylaxis and 11 controls, who received rescue treatment if indicated. Both groups are similar regarding mean body weight, mean gestational age, dosage of Curosurf, etc. Results underwent statistic analysis. Data from the study shows better effect from prophylaxis with Curosurf: smaller number of babies developed RDS and especially RDS grade III-IV (subsequently less babies needed a second dose of Curosurf); higher PaO2/FiO2 ratio; reduced duration of artificial ventilation and of oxygen therapy; reduced incidence of BPD. Results do not show statistically significant difference, but a tendency for ft. As a conclusion: prophylaxis with Curosurf leads to a decrease in the incidence and severity of RDS and to reduced duration of ventilation support and oxygen therapy.

Use of surfactant for prophylaxis versus rescue treatment of respiratory distress syndrome: experience from an Italian-Bulgarian trial

OBJECTIVE

To show if surfactant applied in different social-sanitary realities as prophylaxis of respiratory distress syndrome (RDS) is equally useful and able to reduce mortality and incidence of 3-4 radiological grade RDS.

METHODS AND PATIENTS

Two neonatal intensive care units (NICU) in Italy, one NICU in Bulgaria and one NICU in Romania were involved in a randomized controlled clinical trial of prophylaxis vs rescue treatment of RDS. Babies with gestational age 26-30 wks were randomized before birth to prophylaxis in the delivery-room with 200 mg/kg of porcine surfactant (prophylaxis) or to routine assistance (control). Subsequently the babies developing RDS requiring mechanical ventilation and fraction of inspired oxygen (FiO2) > or = 0.4 to maintain PaO2 about 50 mmHg were allowed to be treated rescue with 200 mg/kg of the same surfactant. To reach end-points of reducing mortality by 40% and incidence of radiological grade 3-4 RDS a total number of 174 patients were required.

RESULTS

Due to logistic, practical and social-political problems the study was interrupted after enrollment of 93 babies (61 in Italy and 32 in Bulgaria). The Romanian centre did not start the study because it was impossible in the scheduled times to equip it for mechanical ventilation of the newborn infants. Analysis done on an intention to treat basis did not show significant reductions of mortality and 3-4 radiological grade RDS, even if there was a trend towards a reduction in the babies given prophylaxis. A significantly lower number of babies given prophylaxis required a subsequent rescue treatment compared to controls (p < 0.001). There was no difference in other complications such as intraventricular haemorrhage, air-leak syndromes and infections between prophylaxis and control infants. As regards pulmonary gas exchange, the PaO2/FiO2 ratio was significantly improved in the babies given prophylaxis for the first 12 hours of life vs the controls.

CONCLUSION

Even if the study was terminated before term, the analysis of the data shows that prophylaxis with surfactant is equally effective in different social-clinical conditions to improve pulmonary gas-exchange, especially in the first critical hours of life of premature babies.

[The mode of delivery in pregnant diabetics]

In our study we have 313 cases--100 cases as a control group and 213 cases as a diabetic group. We studied in these cases the mode of delivery either spontaneous labour, labour induction, cesarean section, forceps and vacuum delivery.

[Current monophasic hormonal contraception]

Data are presented from an investigation of the use of monophasic contraceptive pills chosen by different age groups. Analyses are made of the data obtained from the Bulgarian Association for Family Planning (BAFP) card index for the last two years. Information is given on the number of observed cycles, type of applied contraceptive pill, aims of their application (contraception, treatment of acne, menstrual disturbances etc.), age of patients, as well as any possible adverse effects--change in blood pressure, bodyweight changes, intermenstrual bleeding, hairiness, breast problems, paraclinical changes, etc. The observed cycles show a very small percentage of adverse effects with hormonal contraception, mainly during the first 2 or 3 cycles, with predominance of intermenstrual bleeding. No bodyweight changes or increased hairiness were observed.

[The effect of antenatal corticosteroid prophylaxis in premature newborns with the use of surfactant therapy]

The study is retrospective aiming to elucidate the effect of antenatal corticosteroids (CS) for prevention of RDS in preterm deliveries, followed by surfactant therapy. 28 premature babies from 26 to 31 gest. weeks, receiving Curosurf at birth, were included in the study. They were divided in two groups: group A-17 babies of mothers with CS prophylaxis and group B-11 babies from deliveries without prenatal CS. All babies were followed for incidence and severity of RDS, duration of artificial ventilation and oxygen therapy. Although mean gestational age and body weight are lower in group A, incidence of severe RDS is lower (23.5% versus 36.4% in group B); duration of artificial ventilation with FiO2 > 0.60 and as a whole is smaller (mean 28.9 hrs and 186 hrs v/s 50.3 hrs and 228 hrs resp. in group B; p < 0.05), duration of oxygen therapy is shorter (mean 428 hrs v/s 540 hrs in group B; p < 0.05), smaller is the incidence of pneumothorax, IVH gr. III-IV, inborn infections and death rate although not statistically significant. The conclusion is made that antenatal use of CS improves lung function in premature babies and potentiates the effect of surfactant.

[Pregnancy outcome (perinatal mortality and morbidity) in women with diabetes]

In our study we have 313 cases--100 cases as a control group and 213 cases as a diabetic group. Different types of pregnancy outcome have been studied in these cases (perinatal mortality rate and perinatal morbidity). The most frequent morbidity is from: fetopathy diabetic, congenital malformation, respiratory distress syndrome, preterm delivery, intrapartum traumatic complications (shoulder dystocia, brachial plexus injury, intracranial bleeding, fracture of clavicle), hypoglycemia, hypocalcemia, hyperbilirubinemia.

[Unsuccessful contraception among patients seeking abortion on demand]

We have conducted a prospective study aimed to analyse contraceptive use among women seeking for legal abortion in the State University Hospital "Maĭchin dom"--Sofia. Our date demonstrate that the patients were well informed about the existing contraceptive methods. On the contrary the percentage of women-using contraception and especially those, using highly effective ones is relatively low. The patients claim the possible side effects of the high effective contraception as a reason against use.

[Twin pregnancy. Its incidence]

The authors evaluate changes in the incidence and proportion of the life births by plurality in Mothernal Hospital in Sofia between 1991-1995 and compare it with the incidence of multiple births in other countries in the world. The influence of some factors on the incidence of multiple pregnancy are discussed.

[The use of the preparation Cilest in the practice of the Bulgarian Association for Family Planning]

Data are presented from a questionnaire study on the sexual activity of Bulgarian teenagers as well information on the contraceptive methods chosen by them. The authors inform in short about the activities of the Bulgarian Association for Family Planning (BAFP). Analyses are made of the data obtained from BAFP card-index for the last two years. Information is given on the number of observed cycles, types of applied contraceptive method, aims of their application (contraception, treatment of acne, menstrual disturbances etc.). The attention was concentrated on the third generation contraceptive pills Cilest, on the age of patients, as well as on the adverse effects--change in blood pressure, body-weight changes, intermenstrual bleeding, hairiness, breast problems, paraclinical changes, etc. Underlined is the number of teenagers who seen the BAFP help on problems of contemporary contraception. The observed cycles show a very small percentage of adverse effects with hormonal contraception, mainly during the first 2 of 3 cycles, with predominance of intermenstrual bleeding. No body-weight changes or increased hairiness were observed.

[Diabetic retinopathy during pregnancy]

Diabetic retinopathy is the leading of blindness between the age of 24-64 years and we know the half of this period corresponding to the peak fertility and childbearing years. The prevalence and severity of the retinopathy is strongly related to the duration of the disease and patient age. The progression of diabetic retinopathy during pregnancy can vary from minimal to market deterioration of the retina. So in diabetic women full retinal evaluation must be done as a part of prepregnancy counseling procedure. Patient who already have proliferative retinopathy during pregnancy are monitored frequently by ophthalmologist and lesser photocoagulation can be done safely during pregnancy.

[The medicosocial aspects of contraception for teenagers]

The authors study and examine the influence of some medical and social factors on the teenagers use of contraceptives. The study is based on the questionnaires fulfill by 568 teenagers (aged 13-19). In the enquêtes are shown the role of the family status of the parents the involvement of the family and the school in the sex education, and also are indicated the favorite teenager's contraceptive methods. The positive attitude on contraception and on this kind of researches is very characteristic for 94% of the analyzed teenagers. The authors made a conclusion on optimizing the use of modern contraceptives for teenagers.

Preoperative sonographic evaluation of patients with endometrial carcinoma

OBJECTIVE

The aim of the study was to evaluate the possibilities of endovaginal ultrasound in the preoperative clinical assessment of patients with endometrial carcinoma.

METHOD

Sixty-four postmenopausal women with a diagnosis of endometrial carcinoma after dilatation and curettage were scanned before operation with a 7.5-MHz endovaginal probe.

RESULTS

The location of the process and depth of myometrial invasion were estimated correctly in the vast majority of patients. Spread beyond the uterus and distance from the serosa could not be estimated precisely.

CONCLUSION

Preoperative evaluation and staging of endometrial carcinoma are possible and useful for gynecologists, as they provide information on tumor location, depth of myometrial invasion, and involvement, if present, of the lower uterine segment or cervix.