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Perinatology is a dynamically developing field of medicine. The progress of technology in recent decades has made it possible to recognize birth defects very early, including those which are lethal or genetically determined. In many clinical situations, it is no longer possible to work alone to reach a definitive diagnosis, plan treatment or predict the clinical course of the affected fetus/newborn. There is a need for teamwork, which ensures the proper, early care starting in the fetal period, not only in the delivery room or NICU. This paper discusses the ethical foundations of creating interdisciplinary teams, taking as an example the Interdisciplinary Team for Fetal Malformation at the Institute of Mother and Child in Warsaw, which has been active for 25 years, and presents how it works in practice. On the basis of the clinical cases that are examined, practical guidelines were formulated for both the work of medical teams and the way parents are informed about the clinical situation of their child and about sharing the care after the birth of the child. A document was also proposed with information on prenatal diagnosis, decisions made by the interdisciplinary team regarding the mother and child, as well as the conclusions resulting from discussions with parents.

Background: It has been shown that MRI offers the possibility of more detailed assessment of fetal pathology than sonography. It is used not only to diagnose but also to follow up some prenatal diseases. It is a basis of in utero treatment and the tool of monitoring its efficacy The purpose of the study was to present the authors' experience with prenatal MRI as a method of follow-up of fetal pathology and of monitoring invasive fetal therapy, Material and Methods: The study group consisted of 31 fetuses that underwent two MRI examinations. The first exams were performed at the gestational age of 19-28 weeks (mean: 23.6 weeks), the follow-up between week 20 and 37 (mean: 30.5). The MRI examinations were performed using 1.5 T scanners. SSFSE/T2-weighted images, TSE/ or GRE/T1-weighted images, DWI, FIESTA, EPIGRE were performed., Results: In 5 cases MRI allowed to exclude a suspected pathology: brain anomaly in a healthy fetus, septo-optic dysplasia in a healthy fetus, right-sided CDH in case of a left-sided pathology pentalogy of Cantrell, lack of bladder in a fetus with a small, thick-walled bladder In 4 cases an additional pathology was detected on MRI: CCAM/ pulmonary sequestration with self-regression, cerebellar hypoplasia, rhombencephalosynapsis, tethered cord with syringohydromyelia. In 4 cases MRI was used just to follow-up and showed evolution of the disease in 2 cases: regression of intracerebral hemorrhage, progression of kidney disease. Finally, in 18 cases MRI was performed before and after an open fetal surgery of myelomeningocele showing good outcome in 10 cases and a wide spectrum of complications in 8 neonates: from edema of the transplant only in 4 to recurrent MC in 1., Conclusions: Maternal uterus constitutes a natural "incubator" for the fetus--it is easier and safer to perform diagnostic procedure in utero than in a seriously ill newborn. MRI is a method of choice in the diagnosis and of follow-up in cases of open fetal surgery.

Aim: The purpose of the study was to evaluate the influence of selected prognostic factors for postoperative course and prognosis in newborns with gastroschisis., Material and Methods: A study of all newborns with gastroschisis treated between 2000-2010 in the Clinic of Surgery of Children and Adolescents, Institute of Mother and Child was performed. Data collected from medical documentation included the following: presence or lack of prenatal diagnosis, mode of delivery, gestational age (below or above 37 weeks), birth weight, necessity on transportation from provincial hospitals or transfer within Institute, condition of the bowel (good - little fibrinous inflammation or bad - massive inflammatory peel, necrosis, perforation, atresia), interval between delivery and operation, kind of surgery (primary repair, silo closure), complication requiring secondary operation, period of ventilatory support (PVS), time needed to achieve full enteral feeding (FEF), total length of hospital stay (TH), number and cause of death. Selected information obtained from the data of the patients were separated into two periods of time: 2000-2005 and 2006-2010 for better evaluation of the influence of individual factors on the efficiency of treatment and prognosis. Multivariate logistic regression was used to investigate the association between selected risk factors and end points (PVS,FEF,TH). Statistical analyses were performed using Stata v.10 (College Station, TX, Stata Corporation LP 2007)., Results: During the study period 32 newborns with gastroschisis were treated. Prenatal diagnosis was made in 22 patients (69%) and the mean age of diagnosis was 30.7 weeks. Cesarean section was performed in 25 cases and vaginal delivery occurred in 7 cases. The mean gestational age during delivery was 35.7 weeks, mean weight was 2430 g. Twenty one newborns were delivered before 37 week of gestation, eleven after 37 week. Fifteen patients were transported from provincial obstetrics hospitals, seventeen were transferred within the Institute (from the Obstetrics Clinic to Clinic of Pediatric Surgery). A good condition of the externalized bowel was found in 18, a bad condition in 14 patients (therein necrosis with perforation in 2, atresia in 2). Mean delivery - operation interval was 6.3 hours. The operation was performed till 3rd hour after birth in 12, over 3rd hour in 20 newborns. During the first surgical intervention primary closure was possible in 29 cases, silo was used in 3 patients. Five patients required more than one surgical intervention (2 patients after silo closure and 3 patients after primary repair). For patients who survived mean PVS was 4.6, mean time FEF was 24.7 days, TH was 34.5 days. Five patients died. The reasons for death were heart tamponade in 2 and complications in the course of sepsis in 3 patients. In the period 2006-2010 versus 2000-2005 number of prenatal diagnosis significantly increased (46% and 84% respectively), mean age at delivery decreased (38.6 and 35.3 respectively), period between delivery and operation shortened from 8.8 to 3.8 hours, more patients were operated on during first three hours after birth (7.6% and 58% respectively). The condition of the bowel was assessed similarly in both periods (bad condition 38% and 47% respectively). All deaths occurred in newborns treated in the years 2000-2005. Multivariate logistic regression showed there was one independent risk factor that influenced the two end points: the period of respiratory support and the length of hospital stay, i. e. the delivery - operation interval. Patients with delivery - operation interval over 3 hours after birth had a significantly higher risk of long-standing ventilatory support or death (OR=12.4, 95%CI {1.7, 89.3}, p=0.013) and a significantly higher risk of longer total hospital stay or death (OR=12.7, 95%CI {1.7, 97.0}, p=0.014). None of the factors analyzed had statistical significance with respect to the length of time needed to achieve full enteral feeding., Conclusion: The main independent risk factor having influence on the course of treatment and prognosis was the delivery - operation interval. Early repair of gastroschisis makes primary closure easier and shortens the post-operative course. Newborns with gastroschisis despite progress in prenatal diagnostics, neonatal intensive care and surgical methods remains a serious therapeutic problem requiring multidisciplinary care and long-standing hospital stay.

A combination of maternal serum levels of free beta human chorionic gonadotropin (free beta hCG) and pregnancy-associated plasma protein-A (PAPP-A) and fetal nuchal transluency thickness (fetal NT) has been shown to be an effective approach to screening for fetal trisomies in the first trimestr of pregnancy. A maternal smoking habit is known to influence these serum markers in singleton pregnancies however it has not been yet completely explained. The aim of this study was the investigation of PAPP-A and beta hCG concentrations in smoking women in the first trimester of pregnancy. The study comprised 215 women between 11th and 14th weeks of gestation: 135 cigarette smokers (age range 19-43 years) and 80 nonsmokers (age range 21-42 years). Only normal singleton pregnancies were included. Smoking women were divided into two groups: 75 women smoking during all along the first trimester and 60 women, who stopped smoking before 6 week of gestation. Maternal serum levels of PAPP-A and beta hCG were measured with the KRYPTOR rapid random-access immunoassay analyser (Brahms GmbH, Germany) using time-resolved amplified cryptate emission technology (TRACE). Combinated fetal nuchal translucency (NT), maternal age and biochemical risk estimates were calculated using the Fetal Medicine Foundation risk algorithm. We observed the lower of PAPP-A median values in both smoking groups by about 20% than in nonsmokers (0.86 MoM; 0.84 MoM versus 1.04 MoM; p < 0.01). We also indicated the lower values of beta hCG in smoking women in comparison to the nonsmoking controls, but this difference was not statistically significant. The concentrations of PAPP-A as well as beta hCG were similar in both groups of smoking women. Further studies will be continued to assessment of smoking influence before conception on maternal serum PAPP-A and beta hCG in the first trimester of pregnancy.

Unlabelled: The ductus venosus is the very important part of fetal venous circulation. It plays a central role in return of venous blood from the placenta. This unique shunt carries well-oxygenated blood from the umbilical vein through the inferior atrial inlet on its way across the foramen ovale. Using Doppler ultrasound, it is possible to assess the blood flow in fetal vessels including ductus venosus. It is observed, in animal and human studies, that the typical waveform for blood flow in ductus venosus in early pregnancy can be different depending on numerous conditions e.g. fetal karyotype. This study is performed to assess the physiologic parameters of blood flow in ductus venosus in uncomplicated early pregnancy., Material and Methods: 404 women were examined between 11+0 and 13+6 weeks (+ days) of gestation by ultrasound. Fetal crown-rump length (CRL) was measured to assess the gestational age. The assessment of risk of fetal abnormalities was based on nuchal translucency (NT) measurement. The ductus venosus blood flow with color and spectral Doppler was obtained in all patients. The following features were assessed: pulsatility index (PI), and direction of flow (positive/negative) during atrial contraction (wave A). All cases were followed up to 22 weeks of gestation when the control scan was performed., Results and Conclusions: 30 cases were excluded from the uncomplicated group due to: high risk of fetal abnormalities, fetal loss, confirmed fetal abnormalities and utero-placental pathology. 374 women were considered as uncomplicated pregnancy. In both uncomplicated and complicated groups the mean values for pulsatility index (PI) were established. The mean PI value in uncomplicated pregnancies was: 0.91 (SD +/- 0.32). No significant differences between groups were noticed. In 370 cases of uncomplicated pregnancy the A wave direction was positive but in 1.1% of cases the reverse flow in atrial contraction was observed.

Unlabelled: Evaluation of pregnancy-associated plasma protein A (PAPP-A) and free beta subunit of human chorionic gonadotropin (beta hCG) levels and sonographic assessment of fetal nuchal translucency (NT) in singleton pregnancies between 11 and 14 weeks of gestation--Poland's multi-centers research., Objectives: Pregnancy-associated plasma protein A has been reported to be low in Down syndrome affected pregnancies during the first trimester of pregnancy. Enlarged nuchal translucency (NT) is observed in about 80% of fetuses affected with chromosomal abnormalities and congenital heart defects (CHD)., Material and Methods: The aim of this study were to determine value and the medians of free beta-human chorionic gonadotropin (beta-hCG) and pregnancy associated plasma protein-A (PAPP-A) and nuchal translucency thickness in the first trimester in a prospective study of a non-selected Polish population., Results: All examinations have been performed according to the Fetal Medicine Foundation (FMF) rules. We have included 800 women between 11 weeks 0 days and 13 weeks 6 days gestation into a biochemical examination. Women booked into the clinic were offered screening, using a combination of maternal serum free beta-hCG and pregnancy-associated plasma protein-A (PAPP-A) and fetal nuchal translucency thickness. The maternal serum were measured using the Kryptor analyzer (Brahms Diagnostica). All pregnant women have been divided into 2 groups younger than (first group) and older than (second group) 35 years of age., Conclusions: Nomogrames for free beta-hCG and PAPP-A levels in physiological pregnancy between 11(+0) and 13(6) weeks were determined in the examined population. A positive correlation between PAPP-A and CRL levels, as well as a weak negative correlation between free beta-hCG and CRL, were demonstrated.

Unlabelled: THE AIMS OF THE STUDY WERE: To evaluate range and median values of NT in a large, unselected Polish population; to determine the value of the 95th percentile and the median values for NT for given weeks of late 1st trimester pregnancy and to determine the level of chromosomal aberration risk corresponding to the values of the 95th percentile in the examined groups; to examine the possible correlation between CRL, NT width as well as the mother's age with the risk of the most frequent chromosomal aberrations., Material & Methods: We have retrospective analyzed 7,866 pregnant women. All fetuses of this women had NT measurement performed, as well as CRL and assessed of the most frequent chromosomal abnormalities. The group of pregnant women was divided into 2 subgroups: until and above 35 years old. All population group was divided into 3 subgroups depending on gestational age (11, 12 and above 13th weeks of gestation)., Results: The median of NT in all population group was 1.5 mm and 95th percentile was 2.4 mm, whilst in group with low risk median of NT and 95th percentile were the same and in group with high risk of chromosomal abnormalities respectively 1.5 mm and 2.5 mm. There were strong correlations between maternal age and the risk of most frequent chromosomal abnormalities from NT., Conclusions: The obtained results of median values and the 95th percentiles of NT in the examined group and the age groups under 35 and 35 plus are similar to these quoted by FMF. The risk levels of trisomy of 21st chromosome were similar to the reference values used by FMF. With gestational age, NT value increases in a non-linear way, therefore it is incorrect to use the term "a normal value" for NT, therefore, only the risk level calculated with the dedicated software using NT and CRL measurements with maternal age should be stated.

Objective: Development of ultrasound diagnostic with Doppler examination allows early and and more precise assessement of fetal anatomy and well-being., Design: Evaluation of blood flow parameters in fetal ductus venosus between 11 and 14 weeks of pregnancy was performed., Material and Methods: Fetal anatomy, nuchal translucency, nasal bone and ductus venosus blood flow has been studied with transabdominal probe in 225 consecutive fetuses according to Fetal Medicine Foundation recommendations., Results: From total number of 225 cases finally ten women were excluded from analysis due to absent or reversed A-wave in DV blood flow. In remaining 215 cases mean value of PI was 0,94 (range 0,53-1,88), mean value of Vmax (S-wave) was 42,48cm/s (range 18,7-102,9cm/sek), and mean value of Vmin (A-wave)--11,91cm/s (range 1,13- 37,32 cm/sek)., Conclusions: PI index value slightly decreased with increasing CRL. There was no differences in mean blood flow velocity with CRL for S-wave. A decrease in mean blood flow velocity with CRL was noted for A-wave.

Crouzon syndrome is a cranio-facial dysostosis with autosomal dominant transmission and a birth prevalence of 16.5 per million newborns. Up till now there is no publications in polish medical journals about ultrasonic diagnosis of Crouzon syndrome or of any other craniostenosis. The development of ultrasonography, three-dimensional ultrasonography and in the last years also MRI, allows earlier detection and diagnosis of fetal malformation and enables precise evaluation of his anatomy. The aim of the study is presentatoin Crouzon syndrom diagnosed prenatally by ultrasonography and confirmed moleculary by DNA analysis. We would like to stress the diagnostic problems and the difficult decisions that we encountered.

Conjoined twins are the rarest type of monozygotic, monochorionic, monoamniotic twins--incidence about 1:50000 - 1:100000. A conjoined twin pregnancy is a very special pathology in obstetrics and usually ends prematurely. 40% of twins are stillborn, while 35% die within 24 hours after delivery. The development of ultrasonography and in the last years also MRI, allows earlier detection and diagnosis of fetal malformation and enables precise evaluation of the anatomy, type of malformation and how the twins are conjoined. Chances of survival and way of delivery depends on the degree of fusion of the organs and possibilities of surgical separation. Obstetric care for a women with conjoined twins does not differ from that in a normal twin pregnancy, but the newborns require special medical care after delivery. We would like to stress the diagnostic problems and the difficult decisions that we encountered. The degree of conjoinment in this case excluded surgical separation of the twins. A multidisciplinary team of experts decided to end the pregnancy at 31 wks by cesarean section. Delivery at a later term could increase the risk of uterine rupture and surgical complications.

Until quite recently the diagnosis of cervical pregnancy was an indication for hysterectomy, because of mortality among patients with cervical pregnancy, coming up to 60%. During last 15 years methods of conservative therapy has developed in order to avoid the necessity of hysterectomy and to keep patient's fertility. Among these the most promising method is using of methotrexate (MTX), which is now the most commonly used agent in case of conservative forms for the treatment of cervical pregnancies. It should be stressed successful in treatment of cervical pregnancy in women, who wish to remain fertile, depends on early and proper diagnosis. MTX can be administered up to 13 weeks of gestation, with the highest efficacy between 6-8 weeks of pregnancy. We reported a case of cervical pregnancy treated successfully with methotrexate therapy combined with curettage of the cervical canal and uterine cavity. Serial beta HCG serum determination and ultrasonography were used to diagnose the pregnancy and to monitor therapy. Treatment was effective and the patient reproductive capability was preserved.

Unlabelled: Group B streptococcus is a main cause of perinatal infections and neonatal sepsis. In Poland there is no epidemiological data of the prevalence group B streptococcal colonization in pregnant women and the risk for their newborns., Objectives: The aim of the study is to define the prevalence of streptococcal B colonization in pregnant women and their newborns., Materials and Methods: The pregnant women and their newborns from Obstetric and Gynecology Department of National Research Institute of Mother and Child were included to our study during 2001 and 2002 years. Cervical, vaginal and perianal swab were obtained. Women with positive cultures were treated with antibiotic during labor. The external swabs of their neonate were obtained., Results: 1678 pregnant women took part in our study. The GBS (streptococcus agalactiae) colonization was found in 331 women. The prevalence of pregnant women group B streptococcal colonization in the study is 19.7%. 70 of 203 neonates form mothers with positive results of our screening, had the GBS colonization confirmed. The prevalence of confirmed streptococcal colonization in neonates was 34.5%. One newborn developed early onset neonatal sepsis, during the study period., Conclusions: The prevalence of pregnant women group B streptococcal colonization about 20%. For the prevention of newborns intrapartum infections a major thing is the prevalence of the transmission risk to newborns from mothers with a GBS colonization and the appropriate intrapartum management.

Maternal death during pregnancy, labour and puerperium constitutes the main problem of prenatal medicine and still a major public health topic. In this work we analyses maternal deaths in Poland between 1991-2000. There were 4,404,641 live births and 462 maternal deaths. Among them there were 402 direct ("true") maternal deaths with mortality rate 9.1 per 100,000 live births and 60 indirect maternal deaths (rate 1.4). There were 218 cases of pregnancy associated deaths (rate 4.9). The main causes of direct maternal deaths were as follows: haemorrhage--33.6% (rate 3.1), sepsis--27.3% (rate 2.5), amniotic fluid embolism--22.4% (rate 2.0) and pregnancy induced hypertension 16.7% (rate 1.5). Increasing maternal age is one of important risk factor for mortality. Over 30% of direct pregnancy related deaths were noted within women above 35 years. Unsatisfactory antenatal care, management deficiency and patient's neglect were main risk factor foe fatal outcome. Practical conclusions should be issued as general rules, instructions and recommendations. Between one third to one half of the maternal deaths are considered to have been preventable.