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Conservative management of placenta accrete consists in leaving the entire placenta accreta in situ after vaginal delivery of the fetus. This behavior requires active monitoring the vital signs of mother, genital status and paraclinical indicators for an extended period after birth. Monitoring is suspended after full absorption of the placenta. The success of the conservative approach depends on: the adopted protocol formanagement of placenta accreta, whether the diagnosis is known before birth, the possible of application techniques, reducing blood flow to the uterus, keeping the placental period and others. The smallest success with vaginal birth, is when the diagnosis of placenta accreta is not know in advance and proceed with aggressive attempts to extract the placenta, followed by profuse bleeding from the uterus. As additional methods of securing conservative management is reported use of Methotrexate, with unproven effectiveness and embolization of a. Iliaca interna and a. uterine, which require a qualified team and have a lot of complications. Complications of conservative management of placenta accreta are: febrility and genital bleeding, which are the cause of late hysterectomy in about 35% of cases. lnfestion may be not always prevent by application of broad spectrum antibiotics. Late bleeding is usually associated with an active inflammatory process. Low-grade and low grade temperature increase of leukocytes and CRP may be due to necrotic changes in the placenta without the infection process. Tracking involution of the placenta is through abdominal and transvaginal ultrasound, magnetic resonance, using hysteroscopy through serial monitoring the level of hCG. From literature data the time for resorption of the placenta varies from 4 months to 1 year. It is essential to determine the time when it is safely to extract the placenta move in order to prevent late complications of conservative management. Our experience and some authors suggest that there may be instrumental extraction under ultrasound control at 8-10 days after birth.

Background: Intrauterine fetal death is an agonizing, often unpredictable event. Autopsies of stillborn fetuses, including placentas, umbilical cord and fetal membranes, are performed to clarify the cause of death. Autopsy results are not always easily understood by the patients and difficult to clarify by the specialists., Objective: To evaluate the macroscopic pathological and histopathological changes in placenta, umbilical cord and fetal membranes as a factor in the pathogenesis of intrauterine fetal death., Materials and Methods: Retrospective review of 129 autopsy reports of singleton stillborn fetuses and placentas from 23 to 41 weeks of gestation., Results: Macroscopic and histopathological findings in the placenta, often in combination with inflammatory changes prevailing in premature cases, while macroscopic and histopathological findings in umbilical cord predominate in term stillborn. In 11% of cases there were no specific pathological findings., Conclusions: Pathological analysis of the placenta is essential for clarifying the pathogenesis of stillbirths. Simplifying the classification of pathological results of fetal appendages at autopsy categories--changes in the placenta, changes in the umbilical cord and inflammatory changes may contribute to easier interpretation and allows for comparison of results.

The optimal management of placenta accreta and until now remains unclear. The reasons for this are a rarity of this condition and the considerable heterogeneity of the group under the term "placenta accreta." Total hysterectomy during caesarean section is the most common approach to a known placenta accreta. Planned or emergency perinatal hysterectomy is associated with several complications--damage to the urinary tract, relaparotomiya, massive blood transfusions and stay in ICU. The average blood loss is about 3000 ml. To reduce blood loss in perinatal hysterectomy contribute: preliminary uterine artery occlusion, istmus-coporal longitudinal hysterectomy for extraction of the fetus, placental extraction along with the uterus. To save the woman's uterus at placenta accreta are using the following methods: cutting the uterine wall on which is located the placenta, imposing single stitches covering 2-3 cm in 1 cm, around the placental area; removal of the maximum possible part of the placenta; using longitudinal hysterectomy. So far, there are no comparative studies of the efficacy of different surgical techniques to preserve the uterus cases of placenta accreta. Extraction of the placenta to be done after the administration of uterotonics and devascularization the uterus. To reduce bleeding from the uterus after removal of parts of the placenta and according to the situation can be used: x-back hemostatic sutures from internal side of the uterus, tamponade with gauze roll, balloon catheters or haemostatic mushrooms. Conservative surgical treatment of placenta accreta is not always possible. In hospital Maternity Hospital-Sofia for the period 1986-2000 there were 17 cases of placenta accreta diagnosed only at birth. Maintaining the uterus was successful in 35% of these cases.

Introduction: Stillbirths represent 50% of all perinatal mortality and remain significant and unanswered problem., Objective: To investigate the causes of stillbirths in term and preterm fetuses and place of intrauterine growth retardation in the pathogenesis of antenatal death., Materials and Methods: The study was retrospective for the period 2008 to 2013, covers 217 cases of stillbirths in University Hospital "Maichin dom" Sofia. Gestational age was from 23 to 41 weeks. Inclusion criteria for the study were: antenatal occurred dead and singleton pregnancy. Exclusion criteria: fetal malformations and multiple pregnancies. Thus number of enrolled cases was 153., Results: The causes of stillbirths are different in different groups according gestational age. The cases of unknown cause, abruption of placenta and preeclampsia prevail in preterm group. The term stillborns headed with pathology of the umbilical cord, followed by cases of unknown cause, diabetes and infection. Overall, preterm group stillborn with mass below 10 percentile for the gestational age - 53 % predominate, compared with those born at term - 39%., Conclusions: The incidence of stillbirths is higher in preterm than term born fetuses. The causes of antenatal death in preterm is mainly abruption of placenta and preeclampsia, whereas in term - pathology of the umbilical cord. In premature stillborn intrauterine growth retardation is more common in comparison with those on term. Unexplained antenatal fetal death is more common in preterm fetuses.

TArticle contains a historical overview of the problem Febris puerperalis, as well as contemporary issues. Presented a case with typical clinical picture.

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

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

Unlabelled: Hyaluronic acid is an important component of the extracellular matrix and has a crucial role in wound healing by stimulation of neutrophil migration, fibroblast proliferation and neoangiogenesis., Objective: To study the efficacy of topical application of Bionect (Hialuronic Acid Sodium Sal 0.2%t) in wound treatment after cesarean section., Results: The incidence of edema, infiltration, exudation and superficial blood collections was significantly lower in cases of Bionect application. The results in patients, treated with Bionect makes it a reasonable wound treatment option.

The occurrence of preterm birth (PTB) is dependent on the effects and interaction of various risk factors. The purpose of this study was to determine the role of some of the multiple known risk factors for the onset of spontaneous PTB. Our results show that: the age (<18 and >40) and the weight of the pregnant woman (low weight or overweight), a history of miscarriages before 12 gestation week and mild anaemia (100-110 g/l) are not independent factors for PTB. A more significant dependence exists between PTB and a history of previous PTB, moderate and severe anaemia (Hb below 100 g/l); more than 50% cervical effacement and more than 2.5 cm cervical dilatetion, but their effect on PTB is less manifested compared to the impact of infection (particularly intraamniotic). Directed search for several risk factors in most cases detects pregnant women at high-risk for PTB and makes its prevention possible.

Authors are discussing a rear case of multiple pregnancy--conjoined twins. The case is personal by exact antenatal diagnosis and delivering is made by the author. It is proposed a classification of conjoined twins and theoretical interpretation of pathological mechanism of fusion.

Unlabelled: Asymtomatic infection with group B streptococci in pregnant women, the screening methods concerning colonized patients and the therapeutic approach towards then are still under discussion., Purpose: To determine the effectiveness and clinical use of the selective media Granada in the diagnosis of beta-haemolytic contamination in pregnant women., Materials and Methods: The study is prospective and it comprises one year period. The patients included are pregnant women in the second half of the pregnancy, with or without sings of preterm delivery. Vaginal smear was collected by both standard microbiological technique and selective media Granada. Sensitivity, time of first positive results and the practical use of both methods were compared. The effect of intrapartal prophylaxis with Cefazolin 3 x 2.0 g i.v. was taken into consideration., Results and Discussion: The obtained results demonstrate that for the period of investigation the incidence of asymptomatic contamination with GBS in patients admitted to "Maichin Dom" Hospital is 6.2% for all pregnant women and 16% for the selected study group. The application of both microbiological methods demonstrated similar sensitivity. For the selective media the time needed for diagnose the presence of beta-haemolytic agent was significantly shorter (approximately 16 h). This results defines the media Granada as appropriate for clinical screening and selective prophylaxis of neonatal streptococcal infection.

Prematurely born infants with intraventricular haemorrhage (IVH) suffer significant morbidity and mortality, particularly those infants with high grade haemorrhage. The more premature infants have a higher incidence, experiencing more severe IVH. The etiology of IVH is clearly multifactorial. Prevention, both prenatal and postnatal. These include efforts to prevent preterm delivery. Postnatally, the importance of optimal resuscitation and neonatal care practices is stressed, particularly those which minimize cerebral blood flow fluctuation. 130 premature infants of less than 32 weeks gestation with a very low birth weight (VLBW) and extremely low birth weight (ELBW) were studied. They were divided in four groups: group I (n=35) received Indocid; group II (n=42) received Indocid and Phenobarbital; group III (n=53) received Indocid and Phenobarbital; surfactant. These three groups were compare to a reference group (n=45). Newborns from the main group were given Indocid 0.1 mg/kg from 6-12 h of life and during next three days, Phenobarbital 5 mg/kg first five days after delivery and surfactant in the first 4 hours of life according to the protocol provided with the specific surfactant replacement product. Cerebral netrasaund in 24 hours, day 3, 5 and 10 of life and follow up till one year age were performed. We found that IVH/PVH percentage is lowest in newborns from group III, followed by newborns from group II and group I.

The authors present a case of a 32 year old pregnant woman who is admitted to the Obstetric clinic in the 16th gestational week with a pain in the ileoceacal region of the abdomen and vomitting. The woman has clinical signs of acute abdomen. A clinical diagnosis of acute appendicitis was suggested. During the operation under general anesthesia was found a phlegmonous inflammation of a Mekel diverticulus with perforation as well as local peritonitis and a catharal inflammation of the appendix. The appendix and the Mekel diverticle were removed during the operation. No comlications were observed during the post operative period. No fetal distress was observed during and after the operation Three months later the same patient was admitted to the obstetric clinic in the 32nd gestational week with a diagnosis Threatened premature delivery in ml VIII status post resection of a Mekel diverticle and appendectomy. The patient had pain to the right of the umbilicus and vomiting. The labor was induced and a viable premature infant was born. Two days after delivery there was again a clinical symptoms and signs of an acute abdomen due to ileus. A strangulation of the terminal ileum was found due to adhesions A Debridman and a lavage were performed No complications were observed during the postoperative period. The authors discuss the difficulties which might ensue when the diagnosis acute abdomen is made in a pregnant woman

Utrogestan is a modern progesterone, which shows maximal effectiveness with minimal side effects. It is a natural progesterone in micronized form, which makes it suitable for oral administration and vaginal application with same effectiveness. The aim of our retrospective study was to evaluate the therapeutical effects of Utrogestan in women with threatened abortion in the first trimester. Our experience dated from about one year and a half. Sixty eight women were treated for threatened abortion with a daily dose of 400 mg Utrogestan. The treatment continued at least 14 days/average 21 days/. Utrogestan was administered orally twice daily. The main indications were first or consecutive threatened spontaneous abortion in first trimester. For the period of time no side effects and subjective complaints were established except particular cases of slight headache and dizziness after morning application. Sixty one of the sixty eight women were dehospitalised with healthy pregnancy with no side effects. In our experience we preferred to use the drug in women with lutein insufficiency before pregnancy. We conclude that Utrogestan can be widely applied in Obstetrics with the proper indications, such as threatened abortion in the first trimester. The prophylactic treatment in women with slighter complaints like dull pain and weight Utrogestan is applied one tablet twice daily. In graver cases the starting dosage is two tablets two or three times daily.

Twenty-eight pregnancies in 16 patients with surgically corrected tetralogy of Fallot between 1997 and 2002 at the SBALAG "Maichin dom", Sofia, were reviewed. Most of the patients were well and asymptomatic after surgery, excluding one patient who was functional class III. The patients had a total of twenty-one successful pregnancies and deliveries. There were seven abortions (33%) and two small-for-date babies (12%). None of the infants had any cardiac anomalies. The pregnancies were relatively well tolerated and there were no life-threatening cardiac complications. For a patient with some residual abnormalities after surgical correction of tetralogy of Fallot, it is important to reassess the cardiac state before pregnancy and, if once pregnant, to anticipate the possible occurrence of complications during labor. Compared to the general obstetric population, more women in the study group underwent instrumental vaginal delivery and probably best option was elective ventouse or forceps. In conclusion despite potential difficulties and complications associated with corrected tetralogy of Fallot, careful cardiac and obstetric management resulted in good maternal and fetal outcomes.

The Aim: Of the study is to discuss the need of delivery room cardio-pulmonal resuscitation (DR-CPR) in VLBW and ELBW infants and intensity, to determine its prognostic significance for the neonatal outcomes, and the influence of some perinatal criteria., Materials and Methods: A retrospective study is performed in University Maternity Hospital: Maichin Dom", for the years 1998-1999 including: 61 ELBW (500-999 g) and 122 VLBW (1000-1499 g). Excluded are infants with great malformations., Results: There were 54% survivors in the ELBW and 86.1% in the VLBW group. 1-st min Apgar scores were significantly lower in the ELBW-group 3.5 +/- 1.9 in comparison to the VLBW: 4.9 +/- 1.9 = pH from umbilical artery were lower too: 7.19 +/- 0.16 and 7.24 +/- 0.14 respectively. From 12 ELBW babies with cord arterial pH < 7.1 survived only 3, but all 3 with pH < 7.0 died; 8 from 10 VLBW babies with pH < 7.1 survived. Intubation rates were as followed: ELBW group--82%, 70% in the first 5 min; VLBW group--57% and 34% respectively. Adrenalin and/or chest compression received 6 ELBW infants, 5 of who died and 4 had severe IVH. The same resuscitation received 8 VLBW babies, 4 of who died and 2 survivors had 3-4 grade IVH. Any grade of IVH occurred in 65% of ELBW and in 44% of VLBW infants. Severe IVH was seen in 37% and 16% respectively. Overall, survivors with grade 3-4 IVH were 15% among the ELBW group and 7.6% among the VLBW., Conclusions: Birth weight and gestational age are the most important factors, determining the intensity of DR-CPR and the prognosis in newborns of < 1500 g. Low Apgar scores, cord arterial pH < 7.10, the need of Adrenaline application and/or chest compression by DR-CPR are reliable prognostic criteria for death and poor nevrodevelopmental outcome.

It was made a study of the body dimensions, Apgar evaluation, and frequency of innate body defects in 141 new-borns by mothers with innate and acquired heart valvular defects. It was found that the average values of body weight, height, and the evaluation with Apgar of the new-borns by mothers with heart defects do not deviate from the average values of the same indices of new-borns by healthy mothers. Despite that 90% of the young mothers with heart defects are with light to moderate degree of the heart defect, and with I or II functionality class, the percent of their new-borns born prematurely is big--31.9, compared to 6.6 for new-borns by healthy mothers. In 2.8% of the new-borns by mothers with heart defects, hypotrophy is observed, and in 3.5%--clinical criteria for immaturity. Perinatal death rate is 0.7% and zero for the control group of new-borns--ones born by healthy women. Six cases (6.7%) of new-borns by mothers with heart defects had innate body defects, 4 (4.5%) of which were innate heart defects. The frequency and the kind of the congenital defects in new-borns by mothers with heart defects is discussed.

Unlabelled: The aim of the study is to assess the microbe find in the secretion of the open surgical wounds of the Cesarean Section and the perineal wounds. 81 young mothers have been examined--57 with open perineal wounds on 5th day after the delivery and 24 with open surgical wounds of Cesarean Section on the 7th day after the operation., Results: The west frequent microbe find in the open perineal wounds is Streptococcus group "D" (enterococcus sp.)--53% of the cases and E. coli--26% of the cases. The most frequent microbe find in the open surgical wounds in the Cesarean Section is Enterococcus sp.--42% of the cases and St. aureus--21% of the cases. Considering the effectiveness of Penicillins (Ampicillin, Augmentin, Azlocillin, Karbencillin)--94%-99% against Enterococcus spp. and of Gentamycin against E. coli and St. aureus--90%-95% their application is recommended if is necessary.

It is known from literature influence on cryotherapy on the tissue structures. It's application cause vessel constriction factor for decrease exudative inflammations and edema), save enzyme and immune activity at the cells levels and increases regenerative processes in tissues On the 324 young mothers we fix ice over episiotomies from 1st puerperal day for 3 days. As a control group were episiotomies on the 254 young mothers one cryoprophylaxis. Complications (oedema, inflammatio, or suppuratio) at the 1st group was 5.55% and in the 2nd (control) group was 9.45%. These results give us reason to suppose, that cryoprophylaxis have even non essential effect on the processes on recovery on episiotomies after delivery.