Search

Pregnancies complicated with either pregestational or gestational diabetes mellitus deserve great attention due to their complexity and potential subsequent complications for both mother and the fetus. Based on already proven role of glycemic variability in the development of these, improving glucose monitoring continues to be an important step towards preventing adverse outcomes. Besides already well-established self-monitoring of glycemia, newer devices in the form of continuous glucose monitoring have found their place due to their proven preciseness and non-invasiveness. This paper has the aim to analyze results and conclusions of obtained, newer studies focused on these methods of glucose monitoring and to also give a closer insight of their usability and limitations.

It has been an entire century since the introduction of insulin into clinical practice, which, among other, led to improvements of fertility and pregnancy outcomes of women suffering from gestational diabetes. The prevalence of diabetes worldwide and in Serbia is high and tends to increase as a consequence of modern lifestyle. Nevertheless, modern diagnostic and therapeutic approaches enable people with diabetes to achieve and complete pregnancies without adverse outcomes. Gestational diabetes can be considered as non-communicable disease and efforts should be made to determine its effects on offspring. In the context of COVID-19 pandemic, diabetes mellitus was identified as an important risk factor for severe forms of the disease.

Metabolic changes occur due to the effects of placental hormones such as human chorionic gonadotropin and human placental lactogen in normal pregnancies. These effects enable the development of insulin resistance among all pregnant women, significantly pronounced in the third trimester. In pregnancies complicated by pre-gestational or gestational diabetes mellitus, these changes are more intensive as they affect the fetoplacental unit. In pregnancies complicated by diabetes the increased number of placental macrophages leads to the increased production of different cytokines which include leptin, tumor necrosis factor alpha, and interleukins. This review addresses placental vascular changes that lead to adverse pregnancy outcomes, along with the effects of the maternal hyperglycemia and fetal hyperinsulinemia.

In order to enhance cost-benefit value of the gestational diabetes mellitus screening (GDM) the concept of universal screening i.e., screening of all pregnant women for gestational diabetes, has mostly been abandoned in favor of the concept of selective screening. Selective screening implies that only women with risk factors are being screened for GDM. However, some recent studies have shown that with the application of the selective screening approach, some women with GDM may not receive proper and timely diagnosis. This review addresses the pros and cons of both concepts. It will also discuss screening methods and methods of preparation and performance of oral glucose tolerance test and the interpretation of its results.

Introduction. The pathogenesis of perinatal hypoxic-ischemic brain damage is highly complex. Objective. The aim of this study was to assess the role of oxidative stress in hypoxic-ischemic brain injury and subsequent abnormal neurological outcome in infants with perinatal hypoxic-ischemic encephalopathy (HIE). We estimated perinatal oxidative brain damage measuring activity of glutathione peroxidase (GPX) in cerebrospinal fluid (CSF) as an indirect biomarker of free radical production during cerebral hypoxia-ischemia in correlation with the level of intracellular enzyme neuron specific enolase (NSE) in CSF as a biomarker of extend of brain injury. Methods. Ninety neonates (>32 GA) with perinatal HIE were enrolled prospectively. HIE was categorized into three stages according Sarnat and Sarnat clinical scoring system and changes seen on amplitude integrated EEG. CSF for GPX analysis and NSE analysis was taken in the first 72 hours of life. Neurodevelopment outcome was assessed at 12 months of corrected gestational age. Results. GPX activity in CSF was in good relation with clinical stage of HIE (p

Background/Aim. Diagnosis of perinatal hypoxic-ischemic encephalopathy (HIE) and early prediction neurological outcome is important and difficult. The aim of this study was to determine the prognostic value of amplitude integrated electroencephalography (aEEG) for abnormal neurodevelopment outcome in a neonate with HIE. Methods. A total of 90 neonates > 32 gestational age (GA) with HIE were enrolled prospectively. All neonates with HIE were categorized into three grades according to the Sarnat and Sarnat clinical scoring system (mild HIE, moderate HIE and severe HIE). aEEG traces were recorded with a cerebral function monitor (CFM) during the first 72 h of life. The neurodevelopment outcome was assessed at 12 months of age of corrected gestational age. Results. The pattern of aEEG correlated with the severity of HIE (p < 0.0001) and subsequent neurodevelopment outcome (p < 0.001). We found that aEEG background patterns exhibited superior prediction of abnormal outcomes at 12 months of age (sensitivity of 91.7% and specificity of 94.3%, positive predictive value of 78.6% and negative predictive value of 98.1%) when compared to aEEG seizure (sensitivity of 94% and specificity of 48%, positive predictive value of 57% and a negative predictive value of 92%). Electroclinical dissociation seizure was detected in 28% of the neonates with HIE. Conclusions. Our results confirm that aEEG is simple and accurate bedside diagnostic method for assessing extension of hypoxic-ischemic brain damage and early identification of neonates with perinatal HIE who are at high risk of neurodevelopmental impairment.

Background/Aim. The use of color Doppler neurosonography (cD-US) allows simultaneous examination of parenchymal and vascular cerebral structures. Evaluation of cerebral blood flow velocities (CBFV) and vascular resistance are important in assessment of cerebral circulation in neonates with hypoxic ischemic encephalopathy (HIE). The aim of this study was to evaluate the predictive value of cD-US for abnormal neurodevelopmental outcome in the neonates with HIE. Methods. A total of 90 neonates (>32 weeks gestational age) with HIE were enrolled prospectively. All the neonates with HIE were categorized into three grades according to the Sarnat and Sarnat clinical staging system: mild HIE, moderate HIE, and severe HIE. cD-US was performed simultaneously during the first 24 h of life. Neurodevelopment outcome was assessed at 12 months of age in all the neonates. Resluts. The values of CBFV and the values of index resistance (RI) correlated with the severity of HIE (p < 0.0001) and subsequent neurodevelopmental outcome (p < 0.001). We detected a significant difference in values of CBFV and in values of RI between preterm and full-term neonates (p < 0.01). The cut-off value of RI for poor neurodevelopmental outcomes was 0.81. Conclusions. cD-US could be very useful and safe diagnostic tool for assessing severity of HIE and subsequent adverse neurodevelopmental outcome.

Introduction. There was used color Doppler ultrasonography (cD-USI), allowing simultaneous examination of parenchymal and vascular cerebral structures. The evaluation of blood flow velocities in cerebral arteries is important in the assessment of cerebral circulation in hypoxic-ischaemic and haemorrhagic brain damage in neonates. Objective. The aim of this study was to estimate normal values of cerebral blood flow velocities (CBFV) and Doppler indices - pulsatility index (PI) and resistance index (RI) - in the anterior cerebral artery (ACA) during the first days of life in infants. Methods. CBFV, PI and RI were obtained during the first week of life with cD-US in 70 infants divided in four groups of gestational age (GA): ≤28 gestational weeks (GW); 29-32 GW; 33-36 GW; and ≥37 GW. Infants with congenital malformations, severe perinatal asphyxia, cerebral haemorrhagic lesion, DAP or severe hypotension were excluded. Results. The mean GA of infants was 34.5±5.5 GW (range 26-40 GW) and the mean birth weight (BW) was 2540±950 g (range 750-4000 g). In the 1st group of 10 infants, ≤28 GW, the mean BW was 950±110 g and values of RI were 0.59±0.10 and PI 1.06±0.080. In the 2nd group of 20 infants, 29-32 GW, the mean BW was 1350±290 g and values of RI were 0.60±0.10 and PI 1.10±0.15. In the 3rd group of 20 infants, 33-36 GW, the mean BW was 1950±750 g and values of RI were 0.63±0.08 and PI 1.15±0.30. In the 4th group of 20 infants, ≥37 GW, the mean BW was 3540±950 g and values of RI were 0.65±0.05 and PI 1.18±0.35. Conclusion. Values of CBFV progressively increase with GA and BW due to progressive increase of cardiac output, blood pressure and closing of ductus arteriosus. Values of RI and PI gradually increase with GA and BW as a result of progressive maturation and opening of vascular cerebral bed with a reduction of the cerebrovascular resistance.

INTRODUCTION C-reactive protein (CRP) is the most common diagnostic marker of infection. OBJECTIVE Objectives of this study were to determine the serum CRP level in neonates with sepsis and establish the influence of gestational age (GA) on the CRP level in the first few weeks after birth. METHOD Diagnosis of neonatal sepsis was established by the presence of clinical signs of sepsis, isolation of the causative agent of sepsis and abnormal hematological parameters. All neonates were divided into two groups: early onset sepsis (EOS) and late onset sepsis (LOS). According to GA all neonates were divided into three groups: 10 mg/l for term and near term neonates and >5 mg/l for preterm neonates. The maximum concentrations of CRP were reached 48 hr after the first symptoms of neonatal sepsis. CONCLUSION CRP levels are proportional with increasing GA and body weight in EOS. The effects of gestational age do not influence CRP levels in LOS. Maturation changes in the immune system are the most likely explanation for this and partly the organisms responsible for an infection may be different at different gestational ages and also in EOS and LOS. There is no correlation with serum CRP levels and with the severity of the disease and bad prognosis in EOS.

Introduction Uterine torsion has been defined as a rotation of more than 45 degrees of the uterus around its long axis that occurs at the junction between the cervix and the corpus. The extent of the rotation is usually 180 degrees, although cases with torsion from 60 to 720 degrees have been reported. Aetiopathogenesis of this condition is still unclear. Establishing clinical diagnosis of this condition is difficult, but very important for reducing maternal and fetal morbidity and mortality. Clinical symptoms are either absent or nonspecific, and the diagnosis is usually made at laparotomy. Case outlineA 31-year old patient was admitted to the Institute of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, as an emergency, seven days upon the established intrauterine fetal demise in the 40th gestation week. On uterine examination, the cervical length of 1.5 cm and dilatation of 3 cm were determined, as well as a palpable soft tissue formation, not resembling placenta praevia. Ultrasound examination confirmed fetal demise and exclusion of the presence of placenta praevia. The labor was completed by caesarean section. During surgery, uterine torsion of 180 degrees to the right was diagnosed. There was a stillborn male baby, and the cause of death was intrauterine asphyxia. A fibrosing and calcified accessory lobe 9x6x2.5 cm in size was observed on placental examination, which is a possible sign of initial gemellary pregnancy. Conclusion The clinical presentation of uterine torsion is variable and clinical examination and ultrasonographic scanning may be insufficient for diagnosis. The method of choice for establishing the diagnosis is magnetic resonance imaging. Once the diagnosis of uterine torsion in pregnancy is established, emergency laparotomy is indicated. Following caesarean delivery, it is necessary to surgically remove all the anatomical causes of torsion, and rotate the uterus back to its normal position. There are some authors who suggest bilateral plication of the round ligaments as a preventive procedure for repeated torsion in puerperium and following pregnancies. The effectiveness of this method requires further investigation. It is necessary to have in mind the possibility of uterine torsion in all cases of abdominal pain during pregnancy and dystocia.

Background/Aim. Tibolone is a preparation that belongs to the group of steroidal substances. The effects of the use of the use of tibolone are the consequence of the activities of its metabolities, considering that their hormonal activity depends on the type of tissue in which they develop. The aim of this study was to evaluate the influence of the use of tibolone on risk factors for the development of cardiovascular diseases in postmenopausal women. Methods. A prospective observational stady included 94 patients who had the concentration of l7ß estradiol < 50 pg/ml, and who was in menopause more than a year. Out of the total number of patients, 63 accepted to receive tibolone 2.5 mg daily (tibolone group), while 31 of the patients refused to take tibolone (control group). We measured the concentration of lipids (cholesterol, LDL cholesterol, HDL cholesterol, triglicerides), antitrombin III, fibrinogen, and C-reactive protein, before and after the treatment within a 6-month period. Then, we compared the difference between the values of concentrations and tested the statistical significance of the difference. We also evaluated the changes of values in the concentrations of the examinated parameters inside a 6-month period in the control group. Results. In 31 patients of the control group, from the control group there were no significant changes in the values of the defined parameters as compared to their initial values after six months. But there were changes of statistical significance (p < 0.001) in values of the concentrations of the exeminated parameters before and after the treatment in the tibolone group. In fact, we recorded decreases in the total cholesterol by 17.8%, HDL cholesterol by 27%, LDL cholesterol by 4% (without statistical significance p > 0.05) and triglicerids by 35%. There were no statistical differences in the concentrations of antitrombin III, fibrionogen, and C-reactive proteine in the tibolone group before and after the treatment. Conclusion. The use of tibolone dose decrease the concentration of the total cholesterol, triglicerides, HDL cholesterol, without a significant decrease of LDL cholesterol. Also, the use of tibolone does not have any significant effect on the concentrations of antitrombin III, fibrinogen and C-reactive proteine. The number of serum parameters measured in this study was limited, thus that was the reason to discuss only about the metabolism of lipids in the patients from the tibolone group. The final conclusion about the risk for cardiovascular diseases in the patients on tibolone, howerer, reqnires were extensive further clinical exeminations.

Aim. To compare the effects of two therapeutic protocols for the patients with recurrent miscarriages associated with the presence of antiphospholipid (anticardiolipin) antibodies. Methods. A prospective observational study included 20 patients with antiphospholipid antibodies in the first group who received low-molecular heparin and aspirin. The second group of 20 patients, in addition to this therapy, received immunotherapy (intravenous immunoglobulin). Aspirin was administered at the time of a positive pregnancy test, and low molecular heparin not before the fetal heart activity registration by ultrasound. Intravenous immunoglobulin was given prior to the conception or at the beginning of the pregnancy. We compared these groups according to the pregnancy outcomes and the occurrence of complications during pregnancy, using standard statistical tests. Results. The rate of positive gestational outcome in the patients treated with aspirin and low-molecular heparin was 85% (17/20), and in the second group it was 90% (18/20). There was no significant difference in pregnancy outcomes between these groups (p > 0.05), except for the occurrence of preeclampsia and thrombocytopenia, which were recorded only in the aspirin and low-molecular heparin group, but with no statistical significance (p > 0.05) compared to the second group, which received immunoglobulin additionally. Conclusion. There was no significant difference (p > 0.05) in pregnancy outcomes between the two studied therapeutic protocols, but the therapy with aspirin and low-molecular heparin was cheaper and easier to apply than the therapy with immunoglobulins. The results of our study confirmed that the final pathogenic mechanisms in recurrent fetal miscarriages were inflammation and thrombosis of the uteroplacental blood vessels.

Diabetic ketoacidosis (DKA) is one of the most serious and life-threatening complications of diabetes mellitus (DM), especially when it occurs during pregnancy, with a prevalence ranging from 0.5% to 3%. Pregnancy is considered a susceptible environment for the development of this type of metabolic imbalance due to its inherent physiological changes. Unspecific symptoms (vomiting, diarrhea, abdominal pain, etc.), especially in pregnant women, and the fact that ketoacidosis can develop even with normal glucose values (defined as euglycemic ketoacidosis), often lead to a delayed diagnosis. Evidence suggests that timely diagnosis and appropriate management of ketoacidosis are crucial in preventing adverse outcomes for both the mother and the fetus. Fetal outcomes are often dichotomous, resulting in either fetal demise (miscarriage/stillbirth) with a prevalence of 10% to 35%, or the birth of a healthy baby, with possible complications primarily related to diabetes mellitus itself. Additionally, case reports of ketoacidosis developing even in non-diabetic women due to other diseases (such as acute pancreatitis, appendicitis), as well as in those with gestational diabetes mellitus (GDM), further emphasize the importance of considering this condition in everyday clinical practice. The aim of this paper is to further elucidate the causes and course of this complication, as well as the outcomes for both mother and fetus, to contribute to a better overall understanding.

Objective: To evaluate diagnostic accuracy and efficiency of ultrasound markers of gestational diabetes (GDM) and propose an ultrasound based scoring system suitable for screening (UGDS). Methods: 110 women with singleton pregnancies and established maternal and/or pregnancy related risk factors for GDM were scanned at/or after 24 weeks gestation followed by administration of a 3 hour 100-gram oral glucose tolerance test (oGTT). A number of ultrasound markers were determined/measured, including fetal adipose subcutaneous tissue, asymmetrical macrosomy, cardiac circumference, cardiac width, and interventricular septum thickness, immature appearance of placenta, intensified breathing movements, polyhydramnios and placental thickness. Each ultrasound GDM marker was assigned one point to create the ultrasound gestational diabetes screening score (UGDS). Results: All ultrasound GDM markers were positively correlated to the disease P < 0.0001. The strongest independent predictor of GDM was an immature appearance of placenta (RR 40.1 95% CI 5.9-271.0, P < 0.0001). Receiver operator characteristics (ROC) showed an area under the curve of 95.7% confirming good ability of UGDS to discriminate between positive and negative oGTT. We propose a UGDS score of 4 providing sensitivity of 90.9%, and specificity 89.6%. Conclusions: This study suggests that UGDS is a good predictor of GDM. [ABSTRACT FROM AUTHOR]

Background/Aim. Tibolone is a preparation that belongs to the group of steroidal substances. The effects of the use of the use of tibolone are the consequence of the activities of its metabolities, considering that their hormonal activity depends on the type of tissue in which they develop. The aim of this study was to evaluate the influence of the use of tibolone on risk factors for the development of cardiovascular diseases in postmenopausal women. Methods. A prospective observational stady included 94 patients who had the concentration of l7ß estradiol < 50 pg/ml, and who was in menopause more than a year. Out of the total number of patients, 63 accepted to receive tibolone 2.5 mg daily (tibolone group), while 31 of the patients refused to take tibolone (control group). We measured the concentration of lipids (cholesterol, LDL cholesterol, HDL cholesterol, triglicerides), antitrombin III, fibrinogen, and C-reactive protein, before and after the treatment within a 6-month period. Then, we compared the difference between the values of concentrations and tested the statistical significance of the difference. We also evaluated the changes of values in the concentrations of the examinated parametars inside a 6-month period in the control group. Results. In 31 patients of the control group, from the control group there were no significant changes in the values of the defined parametars as compared to their initial values after six months. But there were changes of statistical significance (p < 0.001) in values of the concentrations of the exeminated parametars before and after the treatment in the tibolone group. In fact, we recorded decreases in the total cholesterol by 17.8%, HDL cholesterol by 27%, LDL cholesterol by 4% (without statistical significance p > 0.05) and triglicerids by 35%. There were no statistical differences in the concentrations of antitrombin III, fibrionogen, and C-reactive proteine in the tibolone group before and after the treatment. Conclusion. The use of tibolone dose decrease the concentration of the total cholesterol, triglicerides, HDL cholesterol, without a significant decrease of LDL cholesterol. Also, the use of tibolone does not have any significant effect on the concentrations of antitrombin III, fibrinogen and C-reactive proteine. The number of serum parameters measured in this study was limited, thus that was the reason to discuss only about the metabolism of lipids in the patients from the tibolone group. The final conclusion about the risk for cardiovascular diseases in the patients on tibolone, howerer, reqnires were extensive further clinical exeminations. [ABSTRACT FROM AUTHOR]

Introduction: Antiaggregational therapy can reduce thrombosis development following the arterial reconstruction surgery. In most cases acetylsalicylic acid and ticlopidine are used as antiaggregational agents., Objective: The aim of this research was to examine the influence of different antiaggregational agents on a long-term femoropopliteal/crural bypass patency., Methods: The study involved 142 patients who underwent femoropopliteal/crural bypass reconstructions at the Cardiovascular Disease Institute of the Clinical Centre of Serbia. Most patient were operated on in the period from December 2007 to December 2009; however, the study also included a certain number of patients who had undergone surgery 1-7 years earlier, and who were postsurgically under a regular check-up and examination. Depending on the administered antiaggregational agents, three groups of the patients were formed: (1) patients on 100 mg/daily acetylsalicylic acid; (2) patients on 2 x 250 mg/daily ticlopidine; and (3) patients on 100 mg/daily acetylsalicylic acid combined with 2x250 mg/daily ticlopidine., Results: Among the formed groups in our study, there was no statistically significant difference in the femoropopliteal/crural bypass long-term patency, and the obtained patency values for each group were in accordance to the data from the literature., Conclusion: The first-choice antiaggregative agent after surgical infrainguinal arterial reconstruction procedures was found to be acetylsalicylic acid as compared to ticlopidin for at least two reasons: low cost and absence of neuthropenia as a side-effect.

Introduction: Nosocomial infections are caused by microorganisms, and they develop 48 hours or more after admission to a hospital. It is considered that these infections are neither manifested nor present during the incubation period at the time of admission., Material and Methods: The objective of our study was to identify the most frequent microorganisms causing nosocomial infections in the Intensive Care Unit of the Institute of Gynecology and Obstetrics. The study included 33 patients, mean age 43.5 +/- 5 years, who were critical cases treated in Intensive Care Unit of the Institute of Gynecology and Obstetrics, Clinical Center of Serbia, in the period 2001 - 2003. All patients were surgically treated, intubated and assisted by mechanical ventilation., Results: The most common causative agents isolated from the endotracheal tube were Staphylococcus aureus, Staphylococcus coagulasa negative and Pseudomonas spp., whereas Escherichia colli and Enterococcus were isolated from the wounds. These are highly resistant strains to antimicrobial agents., Discussion: Two big groups of microorganisms were isolated as causative organisms of nosocomial infections. The first group causes blood stream infections, such as Staphilococcus aureus and coagulasa negative, and the second group causes respiratory infections like Pseudomonas aeruginosa, Klebsiella Enterobacter and Acinetobacter. The mortality and morbidity are very high, up to 40 - 80%., Conclusion: We can conclude that invasive diagnostic procedures are causing a high percentage of nosocomial infections. It is of utmost importance to prevent these infections by early use of antibiotics and infection control which depends on the hospital or clinic.