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Introduction/Objective. Fetal growth restriction (FGR) is associated with increased fetal and neonatal mortality and morbidity. The study objective was to investigate the correlation of maternal blood biochemical markers routinely determined in the first and second trimester screening and ultrasound fetal surveillance parameters in the prediction of fetal growth and condition in singleton pregnancies. Methods. In the first trimester we measured serum levels of beta subunit of human chorionic gonadotropin (βHCG) and pregnancy-associated plasma protein A (PAPP-A). In the second trimester we measured values of chorionic gonadotropin (HCG), alpha fetoprotein (AFP), unconjugated estriol (E3) and inhibin A, also examined ultrasonographic biometric fetal parameters, amniotic fluid index (AFI) and Doppler resistance indexes. FGR was defined as ultrasonographically determined fetal weight and growth parameters below the 10th percentile for the gestational age. Obtained biochemical and ultrasonographic parameters were correlated. Results. Study included 104 singleton pregnancies. βHCG in the first trimester correlated negatively with fetal growth in the second and third trimester, and the second trimester AFI. Increased PAPP-A correlated positively with elevated resistance index in medial cerebral artery, lower biophysical profile scores, and intermediate type of non-stress test. Lower values of E3 were associated with FGR. Elevated serum AFP levels were linked to oligoamnion in the third trimester. There was no correlation of inhibin A levels with fetal condition. Conclusion. First and second trimester biochemical markers of pregnancy (βHCG, PAPP-A, HCG, AFP and E3) in combination with ultrasonographic biophysical parameters of fetus have predictive value for fetal growth and development.

Introduction. Spontaneous bilateral ectopic pregnancy is a rare condition easily overlooked or misdiagnosed. We present a case of spontaneous bilateral tubal ectopic pregnancy and discuss the difficulties in diagnosing and treating such patients. Case outline. A 39-years-old patient with a history of irregular and abundant menstrual cycles complained of pelvic pain and light bleeding after 55 days of amenorrhea. Ultrasound revealed enlarged uterus with a myoma and a heterogenic formation with echogenic ring sign beside the left ovary. Free fluid with clots was present in the pelvis. As the patient was hemodynamically unstable and ectopic pregnancy was suspected, emergency laparotomy was performed. During the surgery we found that both tubes were significantly edematous, dilated, and livid in their ampullary regions. On the left tube anterior wall rupture 15 × 8 mm was noticeable, while right tube was intact with bleeding from its abdominal ostium. Even though the patient was not informed about the possibility of bilateral salpingectomy, after thorough consideration and due to the extent of tubal damage bilateral salpingectomy was eventually performed. Histopathological analysis confirmed the presence of decidua, partially viable and partially necrotic chorionic villi, and trophoblastic tissue in both right and left tubes. Conclusions. Careful preoperative and intraoperative examination of both Fallopian tubes as well as the whole abdominal and pelvic cavity should be mandatory during every assessment of patients with ectopic pregnancy.

The study aimed to assess the oncologic and reproductive outcome of fertility-sparing treatment of stage I borderline ovarian tumors (BOTs). A retrospective study of patients aged 18-40 years with stage I BOTs surgically treated during a 10-year period was conducted. In total, 52 patients (average age 32.7+/-5.9) were followed for 16 to 137 months after BOT diagnosis (mean 73.4 months). The overall survival rate was 100%. Recurrence was registered in 4 patients (7.7%). All patients underwent a unilateral salpingo-oophorectomy and all histologic findings corresponded with primary BOTs (3 serous; 1 endometrioid). Higher parity increased while the histological type and stage did not impact recurrence. Average recurrence-free survival was 36.2+/-23.6 months regardless of histological type and stage. Recurrence occurred during the first 3 postoperative years in 75% of cases. Out of 45 women treated with fertility-sparing surgery, 64.4% attempted pregnancy and the pregnancy success rate was 44.8%. Only one pregnancy was conceived by assisted reproduction, while all others were spontaneous. The fertility-sparing treatment in stage I borderline ovarian tumors can be a safe and successful option both in terms of oncologic and reproductive outcomes, regardless of patient and treatment characteristics. Pregnancies after BOT surgery can be achieved with satisfactory rates and adequate outcomes.

Introduction/Objective. Even with the current treatment, mortality from aortic dissection remains high. The study aimed to evaluate the early postoperative outcome of patients with aortic dissection and identify which factors could influence it. Methods. The study included all consecutive patients who underwent surgery for acute aortic dissection type A from 2012 to 2017. We registered all parameters that could potentially impact the outcome (general data, medical history, clinical and cardiological diagnostic test findings, preoperative complications, type of cannulation and the operation performed, additional surgical procedures, operation duration, etc.). The patients were surgically treated according to the current protocols. The main outcome measures were complications and mortality during a one-month postoperative period. All data collected pre-, intra-, and postoperatively were compared and statistically analyzed. Results. The study included 246 patients, 57.54 ± 12.88 years old on average, and mostly of male sex (74%). Early postoperative mortality occurred in 17% of the patients. Preoperative chronic kidney insufficiency (p = 0.005) and cerebrovascular insult (p = 0.047) and tamponade (p = 0.036) were the major risk factors for postoperative complications and mortality. Long hypothermic cardiac arrest (p = 0.001), cross-clamp (p = 0.017) and cardiopulmonary bypass time (p = 0.036) increased postoperative complications. Postoperative complications started occurring after ≥ 33.5 minutes hypothermic cardiac arrest and ≥ 67.5 minutes cross-clamp time. Postoperative complications occurrence increased (p = 0.034), while performing anterograde cerebral perfusion decreased the frequency of lethal outcome (p = 0.001). Conclusion. The majority of patients surgically treated for acute aortic dissection had good postoperative outcome. However, numerous pre-, intra-, and postoperative factors can impact patient survival.

Background/Aim. It is still under debate in what sense and extent can chorionicity impact the pregnancy outcome of twins without gestational complications specific for monochorionicity. The study aimed to evaluate the effect of chorionicity on healthy twin pregnancy outcome. Methods. The study included patients with uncomplicated twin pregnancies after first trimester that were checked-up and delivered at the Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade during three years (2010–2013). Data regarding mother’s age, comorbidities, parity, presence and type of gestational complications, chorionicity, mode and time of pregnancy ending, birth-weight and Apgar score of twins were determined. Obtained data were compared and statistically analyzed. Results. The study included 361 women with mean age of 33 years. Regardless of chorionicity, twins were mostly born during the 36th gestational week and received Apgar score ≥ 8. Only three monochorionic twins were stillborn, two preterm (29 and 32 gestational week) and one in term (35 gestational week) delivery. Contrary, no intrauterine fetal deaths were recorded. Monochorionicity negatively correlated with having live-born twins (OR = 0.023; CI = [0.001–0.609]; p = 0.024), but was not associated with twins condition at birth, i.e. Apgar score (p = 0.345), pregnancy ending time (p = 0.578) or any other twins characteristic. However, premature preterm membrane rupture and earlier gestational week of pregnancy ending were important confounding factors for relationship between chorionicity and pregnancy outcome. Conclusion. Monochorionicity increases risk for adverse pregnancy outcomes even for uncomplicated, healthy twin pregnancy, but has no influence on the condition of twins who survive until term. If appropriate surveillance and therapy are applied, both healthy twins can be delivered at term regardless of chorionicity.

Background/Aim. Doppler sonography of fetal middle cerebral artery peak systolic velocity (MCA-PSV) can be used to predict fetal anemia and the need for in utero intravascular transfusion (IUIT) in red blood cell (RBC) alloimmunisation pregnancies. The aim of this study was to evaluate whether measurement of MCA-PSV in fetuses that had undergone one to three transfusions is a good diagnostic tool for fetal anemia. Methods. Study included 36 pregnancies treated due to RBC alloimmunisation in our tertiary referral center during the 5-year period (2012–2017). We measured MCA-PSV and hematocrit (Hct) in all patients. In seven pregnancies there was a need to perform sequential IUITs for correction of fetal anemia. In these patients we compared MCA-PSV and Hct values before and after every transfusion. Results. Hct and MCA-PSV correlated negatively before transfusion therapy (p = 0.035) and after the second transfusion (p = 0.046). Contrary, after the first (p = 0.954), before the second (p = 0.738), as well as before (p = 0.092) and after (p = 0,741) the third transfusions there were no significant correlations between Hct and MCAPSV values. Hct values before and after transfusions were positively associated (p = 0.001), but MCA-PSV were not (p = 0.296). According to performed receiver operating characteristic (ROC) analysis the cut-off point of MCA-PSV for investigated patients was 1.22 multiples of its median (MoM). Conclusion. There is a reduction in MCA-PSV accuracy for assessing fetal anemia in previously transfused fetuses. Larger studies are needed to explain the reasons for these findings and potentially set new referral values of MCA-PSV for better diagnostics of fetal anemia.

Background/Aim: Congenital malformations still represent one of the most important causes of prenatal and infant death. The study goal was to analyze occurrence and outcomes of different types of congenital anomalies from the tertiary referral center during a ten-year period. Moreover, study aimed at examining potential predictors of congenital anomalies based on patients’ characteristics and medical history data. Methods: Study included all pregnant women directed to Clinic of Obstetrics and Gynecology Clinical Center of Serbia due to prenatally diagnosed congenital fetal anomalies during past ten years. Upon admission to our clinic a detailed general medical and obstetrical history were taken from every patient. All women underwent genetic testing. Ultrasonography and magnetic resonance were diagnostic methods for fetal malformations confirmation. Results: Study included 773 pregnant women aged from 18 to 46 years. Out of registered nine different groups of fetal anomalies/malformations, the most common were malformations of the central nervous system, while majority of fetuses had combined multiple anomalies. Genetic cause for congenital anomalies was present in 25.2% of pregnancies. Medical pregnancy abortion was performed in 71.8% of cases. Only 10.2% of pregnancies ended in term. The best outcome for children was obtained in case of gastrointestinal anomalies (52% live-born). Contrary only one child with neck and thorax malformations could be saved. According to logistic regression the most important predictor of having a child with combined multiple anomalies was mother’s age, while predictor of central nervous system anomalies was gestational diabetes. The significant predictor of genetic anomalies was mother’s age. Conclusion: In our sample neurological congenital anomalies were the most common, although abnormalities of all organ systems were registered. Majority of pregnancies had to be discontinued due to combined multiple anomalies caused by genetic disorders. Older mother’s age and diabetes can imply on the increased risk for fetal malformations.

Introduction/Objective. As of recently, an increasing number of premenopausal women is being diagnosed with endometrial carcinomas. The objective of our study was to determine if routinely collected clinical and imaging parameters, implying on tumor characteristics, are different in pre- and postmenopausal endometrial carcinoma patients, enabling their appropriate preoperative evaluation. Methods. The study included all patients (n = 209) operated on due to endometrial carcinoma over a period of three years. The diagnosis was based on histopathological findings of exploratory curettage. Medical history was taken for all the patients and they were divided regarding menopausal status. On preoperative ultrasound scan, the endometrial echo pattern was established. The existence of myomas, adnexal masses, free fluid in the abdomen or uterine cavity was noted. Magnetic resonance imaging detected the presence of pelvic metastases and tumor spreading into the uterine cavity, myometrium, cervix, and lymph nodes. Postoperatively, histopathological findings, the tumor stage and grade were established. Results. The majority of women were postmenopausal and secundiparous. Significantly more patients were obese, especially the postmenopausal ones (p = 0.001). Most tumors were endometrioid adenocarcinomas regardless of menopausal status. Irregular/abnormal bleeding (p = 0.037), presence of ascites (p = 0.010), obesity (p = 0.046), and lower parity (p = 0.016) correlated with postmenopausal status. Large exophytic endometrial carcinomas were predominant in younger patients (p = 0.026). Endometrial carcinomas were significantly more often diagnosed in the II FIGO stage in premenopausal patients. There were no other significant differences (endometrial thickness, uterine homogeneity, echogenicity, tumor infiltration and spreading, histopathological type and grade) between pre- and postmenopausal endometrial carcinoma patients. Conclusions. Few differences between pre- and postmenopausal endometrial carcinoma patients existed and the most prominent ones were obesity, parity, irregular/abnormal bleeding, and tumor growth into the cavity.

Background: Gestational hypertension (GH) and preeclampsia (PE) are the most common gestational complications. Several placental biochemical markers are used to predict GH/PE, but with conflicting results. Methods: The study aim was to estimate the biochemical markers' ability to predict hypertensive disorders in pregnancy. On the first ultrasonographic examination, 104 healthy pregnant women were recruited. At the regular pregnancy check-ups, BMI, blood pressure, occurrence of gestational hypertension (early or late onset), preeclampsia, eclampsia and other complications were recorded. Serum concentrations (in multiples of median - MoM) of human chorionic gonadotropin (HCG) and pregnancyassociated plasma protein A (PAPPA) were measured from the 11th to 14th gestational week, while HCG, alpha feto protein (AFP), estriol and inhibin were determined between the 16th and 19th gestational week. Results: Hypertensive disorders throughout pregnancy were diagnosed in 20.2% women. Early-onset GH was registered in 7 and PE in 6 patients, while 14 had late-onset GH and 10 additional women PE. There were no significant differences (p>0.05) in biochemical markers concentrations between women with and without GH/PE. PAPPA levels in the first and HCG in the second trimester correlated with early and late GH/PE. Moreover, higher AFP concentrations were registered in women with preeclampsia signs/symptoms. According to ROC analysis, AFP>1.05 MoM properly identified 80% of GH/PE cases. Obtained models imply that HCG, PAPPA and AFP should be used for GH/PE prediction. Conclusions: Biochemical markers HCG, PAPPA and AFP could be useful in predicting gestational hypertension and preeclampsia. However, different markers should be used for early and late onset GH/PE.

Introduction. Premalignant changes of the uterine cervix occur with similar frequency during pregnancy and in non­pregnant women. Due to the fact that any surgery on the cervix can jeopardize pregnancy, it is important to define the protocol of procedures for the treatment of these changes during pregnancy. Objective. The aim of the study was to investigate the natural course of premalignant cervical changes during pregnancy and the impact of their treatment on the pregnancy course. Methods. Study involved all patients with colposcopically, cytologically and hystopathologically diagnosed premalignant cervical changes during pregnancy from 2002 to 2008. Patients were divided into two groups according to the applied treatment during pregnancy: surgery or monitoring by regular colposcopic and cytological examinations. The two groups were compared concerning treatment outcome, persistence or regression of changes and pregnancy duration. Results. Study involved 58 patients. Spontaneous remission of lesions occurred after pregnancy in 63.79% of cases. Highgrade squamous intraepithelial lesion (H­SIL) demonstrated a higher rate of persistency in comparison with low­grade squamous intraepithelial lesion (L­SIL) (χ2=25.115; p

Background/Aim. The question about the accuracy of cytology and colposcopy is more and more asked due to false positive and negative findings on the basis of which the decision on biopsy is made. The aim of this study was to examine reliability of biopsies based only on abnormal colposcopical findings, before receiving the results of Papanicolaou (PA) smear, by comparing findings of colposcopical, cytological and histopathological (HP) examinations as well as determining validity of these diagnostic methods. Methods. The study involved all patients who had their regular colposcopical and cytological examinations in the outpatient department during a two-year period (2009-2010) in the Clinic for Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade. The material for HP examination was obtained by colposcopically directed biopsy, due to abnormal colposcopical findings and without waiting for PA smear results. The data obtained by these methods were statistically analyzed and compared. Furthermore, validity of colposcopical and cytological examinations was assessed. Results. Out of 127 patients highly significantly more patients had more malignant cervical changes on colposcopical exam compared to HP (p = 0.000), and cytological exam (p = 0.000). Highly significantly more patients had more malignant cervical changes on PA smear than HP exam (p = 0.000), unless when findings were assessed in the widest sense of benign and malignant changes when there were no significant differences in these findings (p = 0,450). Sensitivity of colposcopy as a diagnostic method was 87.5%, specificity 24.14%, positive predictive value (+PV) was 34.65% and negative predictive value (-PV) 80.77%. Sensitivity of PA smear as a diagnostic method was 62.5%, specificity 87.36%, +PV was 69.44%, and -PV 83.52%. Conclusion. Regarding the results of our study it is best to make a decision on treatment according to findings of all the three methods. Cytological analysis is more reliable than colposcopical examination. Therefore, it is advisable that following abnormal colposcopical findings, PA smear should always be taken and only after receiving the results further diagnostics can be planned (biopsy and HP). A final decision on the therapy has to be made based on HP findings which are the only method that can give the ultimate reliable diagnosis of cervical changes.

Background/Aim. Ovarian cancer is the leading cause of death from gynecologic malignancies. Risk of malignancy index (RMI) is recommended in assessment of patients with adnexal masses. The aim of this study was to verify the effectiveness of the RMI in the discrimination between benign lesions and malignant adnexal masses in clinical practice. Methods. Ultrasounds were performed for all the patients and menopausal status, CA125 level and calculated RMI were defined. All the patients were divided into 3 groups depending on RMI (< 25, 25-200, > 200). After operations all adnexal masses were analyzed histopathologically (HP) and then sensitivity, specificity and predictive value of RMI were calculated. Results. Out of a total of 81 patients involved benign tumor had 51 (62.96%) and malignant 30 (37.04%) of the patients. The average value of CA125 in the group of patients with benign adnexal masses was 68.3 U/mL and in the group of patients with malignant adnexal masses it was 581.95 U/mL. In the group of patients with benign adnexal masses the average RMI was 284.9 and in the group of patients with malignant adnexal masses RMI was 469.2. All the results showed a positive correlation between both HP categories and RMI categories. The more malignant HP result produced higher RMI and the cut off value was RMI = 200. Sensitivity of RMI was 83.33%, specificity was 94.12%, positive predictive value was 89.29% and negative predictive value was 90.57%. Conclusion. Our study showed that RMI is very reliable in differentiation benign from malignant adnexal masses.

Background/Aim. Concerning the growth of ovarian carcinoma incidence and bad prognosis for malignant forms, early and precise diagnostics is gaining in importance as a condition for precise and appropriate therapy for ovarian tumor masses. The aim of this study was to analyze pre- and postoperative findings of patients with adnexal masses in order to identify factors which could predict the nature and stage of the tumor prior to surgery. Methods. All patients with adnexal masses who were treated in a 6-month period in the Institute of Obstetrics and Gynecology, Clinical Center of Serbia, (IOG, CCS), Belgrade, had their epidemiologic and gynecologic anamnesis and standard laboratory analyses taken prior to surgery. Also, clinical and ultrasonographic check up of pelvic organs was performed, as well as calculation of body mass index (BMI) and risk of malignancy index (RMI). After surgery we analyzed histopathological (HP) findings of tumors as a mean of final diagnosis and staging. For statistical analysis, we used SPSS 15 program. Results. Throughout a 6-month period, we examined 81 patients with adnexal masses treated in the IOG CCS. HP findings showed that there were significantly more benign (n = 51) than malignant (n = 30) tumors in all the patients (χ2 = 5.512). The patients with malignant HP findings were significantly older than those with benign adnexal masses (t = 3.362; p = 0.001). Significantly more patients with malignant HP findings were in menopause (p = 0.034). BMI values were highly significantly higher in the patients with malignant adnexal tumors (t = 3.421; p = 0.001). There was a statistically significant positive correlation between HP categories (benign, malignant) and RMI categories (low, intermediate and high risk) of all the patients (high risk, more malignant HP) (Roxy = 0.428; df = 78; p = 0.000). Conclusion. Patients in menopause, especially older ones, with high BMI and RMI should immediately be referred to a tertiary level institution, where appropriate surgery could be performed.

Introduction The need for assessing the quality of life in chronic rhinosinusitis is emphasized by the medical, social and economic importance of this pathological condition. Questionnaires have been employed in majority of studies while there are no available data that Q method has been used for quality of life research in chronic rhinosinusitis up to the present. Objective The aim of this study was to identify, group and analyze subjective perception of the impact of the disease on health-related quality of life in patients with chronic rhinosinusitis. Methods The study involved 36 consecutive patients of both sexes, older than 10 years of age, diagnosed with chronic rhinosinusitis in the tertiary health clinic in three successive weeks. They were selected for medicamentous treatment. Health-related quality of life was assessed by Q method. Through 34 representative statements, which were sorted by the examinees related to subjective priorities, 10 key quality of life domains were examined. The data were processed by factor analysis employing specialized software package PQMethod. Results Analyzing individual opinions of the examinees, five different opinion-types (factors) on the impact of chronic rhinosinusitis on quality of life were demonstrated. They were marked numerically and descriptively according to dominant characteristics of the group: Factor 1 - stable group (47.2% of individuals), Factor 2 - symptomatic group (11.1% of individuals), Factor 3 - mental group (5.6% of individuals), Factor 4 - physical group (11.1% of individuals) and Factor 5 - optimistic group (25.0% of individuals). Each group was systematically analyzed. Conclusion Majority of patients with chronic rhinosinusits (72.2%) were found to be satisfied with the quality of life, while just a small number (5.6%) heavily bore the illness which especially jeopardised their mental health. This study demonstrates the strength of Q method in analyzing and categorizing subjectivity and offers quality practical information which enables a more comprehensive approach and more adequate intervention in patients with chronic rhinosinusitis.

Introduction In spite of the advances of modern medicine, puerperal infection is still one of the leading causes of morbidity and mortality of women in postpartal period. Objective The aim of this study was to analyze the presence of microorganisms in the cervicovaginal region of women in labor, as well as the frequency of puerperal endometritis in order to determine optimal treatment for isolated microorganisms and to prevent postpartal endometritis. Methods In this study, all women who gave birth to a healthy child per vias naturalis during the past two years in a tertiary health institution, Institute of Gynaecology and Obstetrics, Clinical Centre of Serbia, were analyzed. The investigation involved 6,391 women in labor. Cervicovaginal smear was taken from all patients before labor, on admission for delivery, and sent to microbiological analysis. Standard procedures of bacterial cultivation were used. For statistical analysis of the results, we used the statistical programme SPSS 15. Results A single microorganism was isolated from each smear of 612 women and in 52 patients two microorganisms were registered in the same smear. We identified 10 sorts of microorganisms, out of which Escherichia coli (in 43.8% of cases), and Enterococcus spp. (in 27.9% of cases) were the most frequent ones. Due to the appropriate approach, there were no cases of puerperal endometritis registered. Reactivity tests showed that Escherichia coli was sensitive to trimethoprim-sulphamethoxazole, Enterococcus spp. to macrolides and cephalosporines, while both types of microorganisms were sensitive to synthetic penicillins and fluoroquinolines. Conclusion The study results show that 10.9% of pregnant women have positive findings of the cervicovaginal smear and that infection prevention should be directed towards Escherichia coli and Enterococcus spp. by administration of the listed antibiotics.

Introduction Female workers in textile and metal industry are exposed to various physical and chemical hazards that can lead to the occurrence of gynaecological diseases. Objective The aim of this study was to estimate the frequency of gynaecological diseases among workers of textile and metal industries. METHOD The investigation comprised 197 female workers, 148 from textile and 49 from metal industry, aged from 26 to 57 years. All subjects were hospitalized based on non-gynaecological diagnoses. Gynaecological diagnoses included: tumours of the genital organs and breasts, cervical ectopy and lacerations, inflammatory diseases, disturbances of static of genital organs, cysts, and irregularities of menstrual cycle. Results Textile workers were significantly younger than metal workers, but the groups were comparable according to total and exposure work-time, qualifications and diagnosis on hospital admission. Gynaecological diseases were diagnosed among all investigated subjects. About 80% were diagnosed with tumours and inflammatory diseases. A highly statistically significant difference was observed among groups according to the presence of cervical ectopy and lacerations, which were more frequent among textile workers. Conclusion Comparison of gynaecological status of workers revealed that, among textile workers, cervical ectopy and lacerations were more frequent than among workers in metal industry. .

In order to determine the risk factors of odontogenic maxillary sinusitis, a total number of 40 patients with this pathological condition was examined in three-year period. Oroantral communication was detected in 40% of patients, oroantral fistula in 25%, sinus foreign bodies in 15% and other pathological conditions in 10% of cases. The extraction of the upper lateral teeth was the cause of odontogenic sinusitis in 65% patients. Given the specific tooth, the first upper molar was the most common cause of the condition, i.e. in 40% of cases. It may be concluded that odontogenic sinusitis is the complication of the oral cavity surgery in 85% of patients, what should be taken into consideration in prevention.