XXXIII Alpe Adria Meeting of Perinatal Medicine · 8 xxxiii alpe adria meeting of perinatal...

XXXIII Alpe Adria

Meeting of

Perinatal Medicine

XXV Alpe Adria

Perinatal Congress

30th September – 01st October 2011.

Zagreb – Croatia

Programme &

Book of Abstracts

3

30th September – 1st October 2011. Zagreb, Croatia

CONGRESS ORGANIZERS:

Alpe Adria Association for Perinatal Medicine

Croatian Society of Perinatal Medicine of the Croatian Medical Association

Department of Obstetrics and Gynecology, Clinical Medical Center – Zagreb

School of Medicine University of Zagreb

Alpe Adria association for Perinatal Medicine

is an Association of Obstetricians and Neonatologists

from Austria, Croatia, Hungary, Italy and Slovenia.

SCIENTIFIC COMMITTEE:

Ante Dražančić, Croatia Marjan Pajntar, Slovenia

Emilja Juretić, Croatia Attila Pàl, Hugary

Marina Ivanišević, Croatia Hajnalka Orvos, Hungary

Sergio de Marini, Italy Gàbor Németh, Hungary

Gianpaolo Maso, Italy Bernard Resch, Austria

Yoram Meir, Italy Uwe Lang, Austria

Tanja Premru-Sršen, Slovenia Wolfgang Walcher, Austria

Lilijana Kornhauser Cerar, Slovenia

LOCAL ORGANIZING COMMITTEE:

Josip Đelmiš, Marina Ivanišević, Emilja Juretić

Secretary: Josip Juras, Marina Horvatićek

Department of Obstetrics and Gynecology, Clinical Medical Center - Zagreb,

Adress: Petrova 13, 10000 Zagreb, Croatia.

Phone +38514604740

Fax +38514604740

E-Mail: [email protected]

[email protected]

ORGANISATION

4

XXXIII ALPE ADRIA MEETING OF PERINATAL MEDICINE

EMA – Poduzeće za zastupanje i trgovinu, Vlaška 106, 10000 Zagreb, Croatia

Providens d.o.o. Kaptol 24, 10000 Zagreb, Croatia

Novo Nordisk Hrvatska, Oreskoviceva 23, 10000 Zagreb, Croatia

Abbott Laboratories d.o.o., Koranska 2, 10000 Zagreb

LIST OF SPONSORS

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TABLE OF CONTENTS

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TIME LIMIT:Introductory lectures – 20 minutes

Invited lectures – 15 minutes including discussion

Free communication – 10 minutes including discussion

REGISTRATION AND REGISTRATION FEE: Please register per e-mail: [email protected] or by Fax +38514604740

There is no registration fee at Alpe Adria Perinatal Meeting.

CREDIT POINTS: There are 15 points for Croatian active and 10 for passive participants.

The foreign participants will get a certifi cate of attendance.

LOCATION OF THE CONGRESS: Auditorium of Clinical Medical Center – Zagreb, Rebro, Kispaticeva 12, Zagreb, Croatia.

INFORMATION

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Programme

XXV Alpe Adria

Perinatal Congress

8


FIRDAY, 30th SEPTEMBER

MORNING SESSION

8.00 - 9.00 REGISTRATION AND OPENING CEREMONY

TOPIC 1: GESTATIONAL DIABETES

9.00 – 9.40 INTRODUCTORY LECTURES

Chair:

Yoram Meir (Italy), Uwe Lang (Austria)

Obstetrics: Hungary

1. Bito Tamas, Nemeth Gabor, Zita Gyurkovits, Orvos Hajnalka, Attila Pal.

Department of OB/GYN. University of Szeged, Hungary.

Gestational diabetes mellitus – obstetric aspects.

Neonatology:

2. Sergio de Marini.

Division of Neonatology, Burlo Garofolo Children’s Hospital Trieste, Italy.

Pediatric aspects of gestational diabetes mellitus.

9


9.40 - 11.00 INVITED OBSTETRIC LECTURES

Chair:

Gàbor Németh (Hungary), Josip Đelmiš (Croatia)

1. Marton Virag, Bito Tamas, Zita Gyurkovits, Nemeth Gabor, Orvos

Hajnalka, Attila Pal.


Comparison of obese and non-obese patients complicated

with gestational diabetes.

2. E Magnet, S Schneuber, Uwe Lang, K Schuster, Th Panzitt.

Department of OB/GYN. Medical University of Graz, Austria.

“One Year HAPO criteria in Graz - a report”.

3. P Podnar, L Steblovnik, I Verdenik, M Tomazic, H Mole,

Tanja Premru Sršen.

Department of OB/GYN. University of Ljubljana, Slovenia.

GDM - guidelines and perinatal results in Slovenia.

4. Yoram Meir, Ruggero Trevisan, Alessia Memmo, Raffaele Tinelli, Paola

Lanza, Daniela Perin, Barbara Giacomazzo, Gabriele Falconi, Andrea

Cocco, Cristina Tumbarello, Giovanni Mammana.

OB/GYN Complex Unit. “San Bassiano” Hospital, Bassano del Grappa,

Vicenza, Italy.

Trends and obstetrical aspects concerning Gestational

Diabetes before and after the new IADPSG diagnostic criteria:

The Bassano del Grappa experience.

5. Oleg Petrović, Vajdana Tomić*.

Department of OB/GYN. University Hospital Center Rijeka,

Croatia.*Department of OB/GYN. Mostar Clinical Hospital,

Mostar,Bosnia and Herzegovina.

Probably new diagnostic outcome-based criteria for

gestational diabetes mellitus.

10


11.00 - 11.30 COFFEE BREAK

11.30 - 12.45 INVITED PEDIATRIC LECTURES

Chair:

Emilja Juretić (Croatia), Bernhard Resch (Austria)

1. Zita Gyurkovits, Judit Bakki, Bito Tamas, Marta Katona*,

Nemeth Gabor, Attila Pal, Orvos Hajnalka.

Department of OB/GYN. *Department of Paediatrics.

University of Szeged, Hungary.

Neonatal outcome of gestational diabetic pregnancies between

2008-2010 at University of Szeged.

2. Nicholas Morris, Bernhard Resch, Wilhelm Müller.

Department of Neonatology. Medical University of Graz, Austria.

Hypertrophic cardiomyopathy in infants of gestational

diabetics.

3. Petja Fister, Gregor Nosan, Darja Paro Panjan.

Department of Neonatology. University Children’s Hospital Ljubljana,

Slovenia.

Gestational Diabetes: Fetal Growth, Perinatal and Neonatal

Features - Experience from 88 cases.

4. de Marini Sergio.


5. Emilja Juretić1, Marcela Ilijić Krpan1, Dunja Anzulović2, Josip Juras3, Iva

Kuliš1, Iva Rukavina1.

1Department of OB/GYN, Division of Neonatology.

2Division of Anaesthesiology and Intensive Care,

3Department of OB/GYN.

Clinical Hospital centre Zagreb. Medical Faculty Zagreb, Croatia.

Neonatal outcome in pregnancies complicated by gestational

diabetes mellitus.

11


12.45 - 13.15 SPECIAL LECTURES SESSION

Chair:

Marina Ivanišević (Croatia), Sergio de Marini (Italy)

1. Gernot Desoye.


GDM: The role of the Placenta and beyond

13.15 - 14.30 LUNCH

14.30 - 16.30 FREE COMUNICATION SESSION

Chair:

Walcher Wolfgang (Austria), Vito Starčević (Croatia)

1. Gernot Desoye.


DALI – A European Effort to Prevent GDM.

2. G Trutnovsky, M Dorfer, E Magnet, Thomas Panzitt.


Gestational Diabetes: Women’s concerns, mood, quality of life

and treatment satisfaction.

3. Philipp Reif, Thomas Panzitt, Franz Moser, Bernhard Resch*, Josef

Haas, Uwe Lang.

Department of OB/GYN. *Division of Neonatology. Department of

Pediatrics Medical University of Graz, Austria.

Short-term neonatal outcome in diabetic versus non-diabetic

pregnancies complicated by nonreassuring fetal heart rate

tracings.

4. Vito Starčević, Dunja Anzulović, Josip Juras, Mislav Herman, Jozo

Blajić.

Department of OB/GYN. Hospital Medical Centre Zagreb. School of

Medicine, University of Zagreb, Croatia.

The infl uence of glycemia control on incidence of

Preeclampsia/ eclampsia in GDM pregnancies.

5. Josip Juras, Marina Ivanišević, Mislav Herman, Horvatiček Marina,

Dunja Anzulović.



The impact of prepregnancy BMI and weight gain during

pregnancy on pregnancy outcome among women with GDM.

12


6. Mislav Herman, Marina Ivanišević, Josip Juras, Horvatiček Marina, Jozo

Blajić.

Department of OB/GYN. Hospital Medical Centre Zagreb, Croatia.

Pregnancy outcome in patients with optimally treated

gestational diabetes mellitus.

7. Gyorgy Vajda1, Z Bagosi2, T Oroszlán2, B Gasztonyi2.

Dept. Ob&Gyn1, Dept. Int.Med2. Zala County Hospital. Zalaegerszeg,

Hungary.

The interdisciplinary care of diabetes in pregnancy.

8. Alenka Višnić¹, Snježana Škrablin², Davor Hulina³.

Department of OB/GYN, Hospital of Pakrac1, Department of OB/GYN.

Hospital Medical Centre Zagreb. School of Medicine,

University of Zagreb, Croatia.

Delaying the delivery after premature rupture of membranes:

cost – benefi t analysis

9. Reich O.


P16/Ki-67 dual-stained cytology testing may predict post-

partum outcome in patients with abnormal pap cytology during

pregnancy.

10. Nenad Veček, Branko Radaković, Tomislav Župić, Davor Petrović,

Snježana Škrablin. Department of OB/GYN. Hospital Medical Centre

Zagreb. School of Medicine, University of Zagreb, Croatia.

Diagnostic ranking weights as supporting system in tertiary

fetal anomaly screening center.

11. L Steblovnik, I Verdenik, M Tomažić, Tanja Premru Sršen.


BMI and GDM as predictors of adverse pregnancy outcome

in Slovenian population in the years 2005-2009.

19.00 DINNER

Restaurant – Okrugljak, Mlinovi 28, Zagreb

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SATURDAY, 1st OCTOBER

MORNING SESSION

TOPIC 2: HYPERTENSIVE DISORDERS

8.00 - 8.40 INTRODUCTORY LECTURES

Chair:

Snježana Gverić Ahmetašević (Croatia), Atila Pal (Hungary)

Obstetric:

1. Mila Červar Živković.


Management after severe forms of Preeclampsia/Eclampsia/

HELLP Syndrom.

Neonatology:

1. Gregor Nosan.

Department of Neonatology, Division of Pediatrics, University Medical

Centre Ljubljana, Slovenia.

Neonatal consequences of Hypertensive disorders in

pregnancy.

8.40 - 10.00 INVITED OBSTETRIC LECTURES

Chair:

Mila Červar Živković (Austria), Sergio de Marini (Italy)

1. Nemeth Gabor, Zita Gyurkovits, Orvos Hajnalka, Bito Tamas, Attila Pal.


Hypertension and pregnancy outcome (one year experience).

2. C Stern, D Ulrich, Mila Červar Živković.


Pregnancy outcome in women with previous Preeclampsia:

A 5-year follow up.

3. B Sajina Stritar, M Drušković, N Tul Mandić, Tanja Premru Sršen.


Uterine arteries doppler in fi rst trimester.

14


4. Giuseppina D’Ottavio, Matteo Ceccarello, Giovanni Di Lorenzo, Vera

Cecotti. Department of Obstetrics and Gynaecology, Institute for

Maternal and Child Health – IRCCS “Burlo Garofolo” – Trieste, Italy.

First trimester pregnancy screening: PLGF, PAPP-A, PP-13,

uterine artery doppler and maternal caracteristics in the

prediction of hypertensive disorders.

5. Snježana Škrablin, Vesna Elveđi Gašparović, Nenad Veček, Trpimir

Goluža, Alenka Višnić.



Aggressive versus expectant management of severe

preeclampsia in preterm gestations.

10.00 - 10.30 COFFEE BREAK

10.30 - 11:45 INVITED PEDIATRIC LECTURES

Chair:

Judit Kiss (Hungary), Mislav Herman (Croatia)

1. Judit Kiss.

Department of Paediatrics. University of Szeged, Hungary.

Hypertension and neonatal consequences.

2. F Reiterer.


Management of hypertension in the newborn.

3. Gregor Nosan.

Department of Neonatology, Division of Pediatrics, University Medical

Centre Ljubljana, Slovenia.

Neonatal hypertension.

4. Italy – not recieved

5. Snježana Gverić Ahmetašević, Ana Čolić, Sonja Anić Jurica.

Department of paediatrics. Hospital Medical Centre Zagreb. School of


Neonatal outcome of preeclamptic pregnancies.

15


11.45 -13.35 FREE COMMUNICATION SESSION

Chair:

Snježana Škrablin (Croatia), Marko Vulić (Croatia)

1. E Weiss, F Prüller, Mila Červar Živković.


Thrombophilia screening in women after Preeclampsia/

Eclampsia/HELLP-Syndrom. A 5 years follow-up.

2. Mila Červar Živković1, M Dieber Rotheneder1, S Barth1,4, T Hahn1,3,

G Kohnen2, B Huppertz3, Uwe Lang1, Gernot Desoye1. 1Department of Obstetrics & Gynaecology. 3Institute of Cell Biology,

Histology and Embryology, 4Institute of Biochemistry and Molecular

Biology. Medical University of Graz, Austria. 2Department of Pathology,

Western Infi rmary, University of Glasgow, UK.

Endothelin-1 stimulates proliferation of fi rst trimester

trophoblasts via the A- and B- type receptor and invasion

via the B-type receptor.

3. M Dieber Rotheneder, S Beganovic, M Fellner, Uwe Lang, Gernot

Desoye, Mila Červar Živković.

Department of Obstetrics & Gynaecology, Medical University of Graz,

Austria.

Endothelin/endothelin receptor system is upregulated

in preeclampsia with or without fetal growth restriction

in contrast to gestational diabetes.

4. K Mayer Pickel, M Mörtl, W Schöll, C Stern, Uwe Lang, Mila Červar

Živković.


Individual Treatment of Antiphospholipid Syndrome

in Pregnancy.

5. C Stern, E Mautne, M Deutsch, K Mayer-Pickel, Uwe Lang, Mila Červar

Živković.


Quality of life in women after hypertensive pregnancy

disorders.

6. E Steinbauer, N Weiss, F Prüller, C Stern, M Häusler, Uwe Lang,

Mila Červar Živković.


Special Management of Thrombophilia in Pregnancies after

Preeclampsia/Eclampsia/HELLP Syndrom.

16


7. T Idris, S Gramm, M Häusler, Uwe Lang, Mila Červar Živković.


Uterine artery Doppler in high risk pregnancies; the prediction

for maternal hypertensive diseases and intrauterine growth

restriction (IUGR).

8. Vassiliki Kolovetsiou, C Stern, C Meyer-Pickel, D Ulrich, T Idris, Uwe

Lang, Mila Červar Živković.


The management of chronic hypertension in pregnancy.

9. Vassiliki Kolovetsiou, C Stern, T Idris, D Ulrich, C Meyer-Pickel, Uwe

Lang, Mila Červar Živković.


A retrospective evaluation of the classifi cation of hypertensive

diseases in pregnancy at the Department of Obstetrics and

Gynecology, Medical University of Graz, Austria.

10. Marko Vulić, Damir Roje.

Department of Obstetrics and Gynecology. University Hospital Split.

Croatia.

Perinatal outcome in gravida older than 35 years with

preeclampsia.

11. Vesna Sokol.

Department of OB/GYN. Hospital Medical Centre Zagreb.

School of Medicine, University of Zagreb, Croatia.

HELLP Syndrome.

12. Vesna Elveđi Gašparović, Snježana Škrablin, Trpimir Goluža, Petrana

Beljan*, Kristina Kotorac*, Rikić Josipa*.

Department of OB/GYN. Hospital Medical Centre Zagreb.

*School of Medicine, University of Zagreb, Croatia.

Perinatal outcome in women with recurrent preeclampsia

versus preeclampsia in nulliparas.

CLOSING CEREMONY

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Th e Book of Abstracts

Alpe Adria

Perinatal Congress

18


GESTATIONAL DIABETES MELLITUS – OBSTETRIC ASPECTS.

Bito Tamas, Nemeth Gabor, Zita Gyurkovits, Orvos Hajnalka, Attila Pal.


Gestational diabetes mellitus (GDM) is a disturbance of the carbohydrate metabolism with different se-

verity and with onset or fi rst recognition dutring the ongoing pregnancy. From this defi nition it is cleare,

that GDM is not a homogenous entity, furthermore, those pregnant women with previous GDM should

considered to be pregestational diabetic patient. The progressive decrease in insulin sensitivity due to

the increasing placental hormone production by increasing gestational age leads to the impaired glu-

cose tolerance. GDM is one of the most frequent complications during pregnancy with increased risk of

maternal, fetal and neonatal complications and also means a risk for subsequent developement of type

2 diabetes mellitus both in the mother and her offspring. Therefore, universal screening (every pregnant

women without known diabetes mellitus or impaired glucose tolerance) for GDM is recommended at

gestational weeks of 24 to 28, but those with risk factor(s) for GDM (obesity, diabetes in family, previ-

ous pregnancy with stillbirth or fetal marformation, policystic ovary syndrome) should undervent earlier

screening. The most widely accepted diagnostic methods are the 2 hours 75g or the 3 hours 100g oral

glucose tolerance tests (recommended by the WHO and ADA, respectively). Once GDM is diagnosed,

quantitative diet is recommended with calory intake of 1200 to 1400 kcal divided to 5 to 6 meals per

day. Approximately, 10% of the gestational diabetic cases requires insulin treatment based on the daily

glucose profi le. Of course, fetal growth and intrauterine well-being as well as further complications

(pregnancy induced hypertension) should be controlled by the follow-up. Termination of pregnancy

after the gestational weeks of 38 is recommended in case of insulin treatment, alteration of fetal growth

or amniotic fl uid volume and previous s tillbirth. Monitoring of fetal hearth rate is recommended during

labor. Elective caesarean section is recommended in case of estimated fetal weight over 4500g. The

insulin requirement decreases rapidly after delivery. The reclassifi cation of the carbohydrate metabo-

lism 6 weeks after delivery then yearly follow-up is recommended.

INTRODUCTORY LECTURES – GESTATIONAL

DIABETES MELLITUS

19


PEDIATRIC ASPECTS OF GESTATIONAL DIABETES MELLITUS.

Sergio de Marini.


XXXxxxx

20


COMPARISON OF OBESE AND NON-OBESE PATIENTS COMPLICATED WITH GESTATIONAL DIABETES.

Marton Virag, Bito Tamas, Zita Gyurkovits, Nemeth Gabor, Orvos Hajnalka, Attila Pal.


Introduction. The adverse impact of overweight on pregnancy outcome has been published in nu-

merous articles; however, patients with GDM were commonly excluded from the examined population

in these publications.

Objective. The aim of this study was to evaluate the effect of overweight on pregnancy outcome in

patients with GDM.

Method. Different data of women with GDM, who gave birth in the University of Szeged Faculty of

Medicine Department of Obstetric and Gynecology between 2007 and 2009, were retrospectively

analyzed. Two groups (BMI < 30, BMI > 30) were generated based on body mass index (BMI) and

pregnancy outcomes were compared.

Results. In the group of normal weight and overweight (BMI < 30) 231 patients were included; the

obese group contained 125 women. The rate of cesarean section in the obese group was signifi cantly

elevated as compared to the group of BMI < 30 : 42.8% and 53.5%. In the obese group, the umbilical

cord pH and the blood glucose level of the newborns were not signifi cantly lower.

Conclusion. Similar tendencies were prevailed in pregnant women with GDM according to the in-

crease of BMI than in the nonGDM population, however the growth of cesarean section prevalence was

less remarkable. In spite of our previous expectation, there was no signifi cant difference in the rate of

patients with insulin treatment between the two groups.

INVITED OBSTETRIC LECTURES

21


“ONE YEAR HAPO CRITERIA IN GRAZ - A REPORT”.

E Magnet, S Schneuber, Uwe Lang, K Schuster, Th Panzitt.


Introduction. Gestational diabetes is defi ned as an impaired glucose disorder, which is fi rst diagnosed

in pregnant women. The oGTT is an implementation in the “Mutter Kind Pass” as screening instrument

for GDM.

Based on the fi ndings of Weiss in the seventies and eighties, the Grazer Department used rigorous cut

off levels (90/160/140 mg/dl) to diagnose GDM, determined by capillary blood samples. In our own data

collection of 1993 – 2003 we found an incidence rate of 4-5% GDM.

According to the consensus panel recommendations from the IADPSG (The International Association

of the Diabetes and Pregnancy Study Groups) , which are based on the HAPO study, the method of

glucose measurement was changed from capillary blood samples to venous blood plasma samples.

Also, an adaptation of the cut off levels (92/180/153mg/dl) was implemented.

Recent literature indicates that the newly proposed criteria for diagnosing gestational diabetes will re-

sult in a gestational diabetes prevalence of 17.8%, doubling the numbers of pregnant women currently

diagnosed.*

This study examines whether the different measurement methods of the oGTT have an impact on the

incidence of gestational diabetes in patients at the Department of Obstetrics and Gynecology at Medi-

cal University Graz.

Methods. Overall 200 pregnant women were included in this analysis. In 100 patients glucose mea-

surement was obtained by capillary extraction; venous extraction was performed in the remaining 100

patients. Statistical analysis was carried out by using SPSS and Microsoft Offi ce Excel.

Results. In our recent data we found an incidence of 16% GDM before the adaptation of collection

methods and cut off levels. An increase of 2% was observed using the new procedure (18% GDM).

Compared to the data collection of 1993 – 2003 that showed an incidence rate of 4 -5 % GDM, a qua-

druplicating of this disease became evident.

Reasons for this may be a changed life style, an increasing average BMI and the severe increase of

metabolic syndrome in Europe.

* E. A. Ryan, Diabetologia. 2011 March; 54(3): 480–486.

SLOVENIA

22


GDM - GUIDELINES AND PERINATAL RESULTS IN SLOVENIA.

P Podnar, L Steblovnik, I Verdenik, M Tomažić, H Mole, Tanja Premru Sršen.


Xxxx

23


TRENDS AND OBSTETRICAL ASPECTS CONCERNING GESTATIONAL DIABETES BEFORE AND AFTER THE NEW IADPSG DIAGNOSTIC CRITERIA: THE BASSANO DEL GRAPPA EXPERIENCE.

Yoram Meir, Ruggero Trevisan, Alessia Memmo, Raffaele Tinelli, Paola Lanza, Daniela

Perin, Barbara Giacomazzo, Gabriele Falconi, Andrea Cocco, Cristina Tumbarello,

Giovanni Mammana.

OB/GYN Complex Unit. “San Bassiano” Hospital, Bassano del Grappa, Vicenza, Italy.

Background. In 2008-09 after the publication of the HAPO study1, the International Association of Diabetes

and Pregnancy Study Groups (IADPSG) developed the revised recommendations for diagnosing GDM2. On

the 27th of march 2010 an Italian National Consensus Conference on GDM diagnostic criteria was held in

Rome and the IADPSG recommendations were fully adopted3. In November 2010 an offi cial “Antenatal Care

Guideline” of the Italian Ministry of Health was issued and in the chapter concerning GDM, the accepted

diagnostic criteria for this condition are the WHO and NICE criteria4. As a consequence, controversy and

discrepancy concerning GDM diagnostic criteria among health care professionals are the rule in Italy.

Purpose of this study was to analyze the obstetrical trends before and after the introduction of the new GDM

diagnostic criteria and to evaluate their clinical impact in our settings.

Population and Methods. Between 01/01/2009 and 31/05/2011, 3305 singleton pregnancies were deliv-

ered in the OB/GYN Unit of Bassano del Grappa (Vicenza, Italy). Since previous diagnostic criteria, based on

a two step approach: screening with OGCT 50 gr – thresholds 95/140 and eventual subsequent OGTT 100

gr of glucose with thresholds 95/180/155/140 was the rule predominantly adopted in Italy until the fi rst tri-

mester of 2010, the population was divided into 2 groups: I group: those who delivered between 01/01/2009

and 31/05/2010 (old criteria): 1950 cases II group: those delivered between 01/06/2010 and 31/05/2011

(mixed criteria): 1355 cases The pregnancy and delivery registry database was consulted in order to analyze

the frequency of GDM, the mode of delivery, the frequency of macrosomia and eventual neonatal brachial

plexus injury, and the association with hypertensive disorders in the 2 groups examined. For statistical

analysis the chi square and the Fischer exact test were used. Statistical signifi cance was reached if p< 0,05.

Results. In 103 out of 1950 (5,3%) pregnancies were complicated by GDM in the I group, while the same

diagnosis was put in 180 out of 1355 (13,3%) pregnancies in the II group. Babies weighting > 4000 gr ac-

counted for 12,6% and for 9,4% of the babies in groups I and II, respectively. Non elective caesarean section

rate (previous CS, abnormal presentation, and other elective indications were excluded) were 24,3% and

17,8% in groups I and II, respectively. Hypertensive disorders were associated in 9,7% and in 7,8% of GDM

cases in groups I and II respectively. No case of shoulder dystocia with brachial plexus injury was registered

in either group.

Conclusions. Although not adopted by all gynecologists, the IADPSG revised criteria almost triplicated

(5,3 → 12,3%) the frequency of GDM diagnoses in our settings. The incidence of macrosomia, the caesare-

an section rate and the association with hypertensive disorders demonstrate clearly that we are dealing with

differently characterized populations. The dilution of serious consequences of hyperglycemia in pregnancy

in a wider population makes it harder to correctly focalize the clinical attention and intensity of surveillance.

To many pregnancies with very mild glycemic disorders, possibly without any perinatal consequence, will be

tagged as complicated pregnancies and as such treated. With the high caesarean section rate in Italy and

the fear of litigation, instead of lowering CS rate, the introduction of the revised criteria will probably cause

further increase in operative deliveries, hospital admissions and costs to the health care system.

References.1. The HAPO Study Cooperative Research Group. Hyperglycemia. and adverse pregnancy out comes.

N Engl J Med 2008;358:1991-2002.

2. International Association of Diabetes and Pregnancy Study Groups Consensus Panel International

Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and

classifi cation of hyperglycemia in pregnancy Diabetes Care 2010;33:676-82.

3. AAVV. Conferenza nazionale di consenso per raccomandazioni e implementazione delle nuove linee guida

per lo screening e la diagnosi del diabete gestazionale (GDM). Disponibile all’indirizzo:

http://www.simel.it/notizie/documento-102873

4. Linea Guida Nr. 20: Linea Guida del Ministero della Salute: Gravidanza fi siologica. Consultabile nel sito

internet http://www.snlg-iss.it

24


PROBABLY NEW DIAGNOSTIC OUTCOME-BASED CRITERIA FOR GESTATIONAL DIABETES MELLITUS

Oleg Petrović, Vajdana Tomić*

Department of OB/GYN. University Hospital Center Rijeka, Croatia.*Department of OB/GYN. Mostar Clinical

Hospital, Mostar,Bosnia and Herzegovina.

Abstract. The aim was to assess reliability of the current gestational diabetes mellitus (GDM) diagnos-

tic criteria for prediction of specifi c adverse pregnancy outcomes, and to establish probable new diag-

nostic outcome-based criteria. A cohort study was conducted on 1,002 pregnant women who were

selected on the grounds of the risk factors for GDM. The participants underwent a modifi ed glucose

tolerance test (OGTT) with 75g of glucose. Information on OGTT results and pregnancy outcomes that

were collected from medical records has been used for identifi cation of specifi c GDM adverse out-

comes. Macrosomia, caesarean section due to cephalopelvic disproportion, infant’s stay in the NICU

> 24 hours, and neonatal hyperbilirubinemia were identifi ed as specifi c adverse pregnancy outcomes.

In the study group of participants with one or more specifi c adverse outcomes, mean glycemic values

during the modifi ed OGTT (4.2±1.0 mmol/L at 0 min, 6.8±1.7 mmol/L at 30 min, 7.9±2.1 mmol/L at 60

min, 7.7±2.3 mmol/L at 90 min and 7.5±2.3 mmol/L at 120 min) were signifi cantly higher than mean

glycemic values in the control group of participants without specifi c adverse outcomes. In conclusion,

with newly proposed GDM diagnostic criteria and determination of serum HbA1c concentrations in

8 – 12 week intervals, antenatal control of hyperglycemia and its complications may be more effi cient.

Detected higher rates of GDM burden health care system, but it is expected to reduce additionally the

associated fetal and maternal morbidity.

25


NEONATAL OUTCOME OF GESTATIONAL DIABETIC PREGNANCIES BETWEEN 2008-2010 AT UNIVERSITY OF SZEGED.

Zita Gyurkovits, Judit Bakki, Bito Tamas, Marta Katona*, Nemeth Gabor, Attila Pal,

Orvos Hajnalka.

Department of OB/GYN. *Department of Paediatrics. University of Szeged, Hungary.

Objective. To evaluate the neonatal complications in infants born to mothers with gestational diabetes

mellitus (GDM).

Methods. Between 01 January 2008 and 31 December 2010, a retrospective analysis was carried

out at University of Szeged, Department of Obstetrics and Gynaecology, with regard to the neonatal

outcome of gestational diabetic pregnancies.

Results. During this three years period, 561(6.7%) neonates were born to gestational diabetic mothers,

out of the total of 8332 neonates. Out of the 561 infants, 106 (18.9%) were born preterm, before 37th

weeks of gestation. 291 (51.9%) were delivered by caesarean section, 8 (1.4%) by operative vaginal de-

livery, and 262 (46.7%) by vaginal delivery. 101 (18.0%) neonates were large for gestational age and 30

(5.3%) small for gestational age. Congenital anomaly was diagnosed in 21 (3.7%), hypoglycaemia in 58

(10.3%), respiratory disorder in 16 (2.8%), polycythaemia in 29 (5.2%), hyperbilirubinaemia in 161 (28.7%)

and cardiomyopathy in 2 (0.4%) cases. 27 (4.8%) neonates were admitted to the Neonatal Intensive

Care Unit. We have lost one fetus in utero at 29 weeks of gestation, but there was no neonatal death.

Conclusions. Serious perinatal complications specifi cally associated with GDM are rare. The tight

glycemic control prior to conception and during pregnancy can prevent an excess rate of congenital

malformations, birth trauma, respiratory disorders. Hypoglycaemia and macrosomia have been dem-

onstrated to be the predominant adverse outcomes in cases of GDM.

INVITED PEDIATRIC LECTURES

26


HYPERTROPHIC CARDIOMYOPATHY IN INFANTS OF GESTATIONAL DIABETICS

Nicholas Morris, Bernhard Resch, Wilhelm Müller.


Over the past two decades fetal echocardiography has become a well established tool in the prenatal

assessment of structural and functional heart disease.

Accurate evaluation of cardiac morphology and function are now possible due to high resolution imag-

ing and Doppler interrogation. Nevertheless there remains a paucity of knowledge and therefore rec-

ommendations on the assessment and management of fetal and neonatal cardiomyopathies.

Small case series and case reports describe the antenatal diagnosis, post natal management and clini-

cal course of this heterogenous group of patients.

Maternal diabetes is one of the leading causes of Hypertrophic obstructive Cardiomyopathy (HOCM) in

neonates, with Typ I and Typ II Diabetes being responsible for most of these cases. Gestational diabe-

tes is more common than pregestional diabetes but only in few cases responsible for HOCM.

The aim of this review of the literature was to establish recommendations for the prenatal and postnatal

management of infants of gestational diabetics, with the aim to recognise patients at risk of HOCM

requiring monitoring, possibly treatment and follow up, but also to avoid unnecessary investigations.

Based on the reviewed literature, in diet-controlled gestational diabetics we recommend routine ultra-

sound screening of fetal morphology with additional monthly ultrasounds from 24 weeks of gestation

onwards to monitor fetal growth.

In all fetuses of insulin dependant gestational diabetics and in all macrosomic fetuses we recommend

an additional ultrasound examination performed in a higher level centre.

In infants with antenatally diagnosed HOCM, treatment and follow up should be determined on an

individual case base with input from a paediatric cardiologist. Very few of these cases will be of clinical

signifi cance.

We do not recommend routine echocardiography in newborns of gestational diabetics unless there is

suspicion of structural heart disease from antenatal scans or concern from clinical examination.

27


GESTATIONAL DIABETES: FETAL GROWTH, PERINATAL AND NEONATAL FEATURES - EXPERIENCE FROM 88 CASES.

Petja Fister, Gregor Nosan, Darja Paro Panjan.

Department of Neonatology. University Children’s Hospital Ljubljana, Slovenia.

Background and Aims. Diabetes is the most common medical complication of pregnancy. The pur-

pose of this study was to examine the clinical characteristics of newborns of mothers with gestational

diabetes (GD).

Methods. In a retrospective study of newborns, admitted to our department in the last 8 years, the

entire inpatient charts were reviewed and data on the fetal growth, perinatal and neonatal features and

neurodevelopmental outcome in infants of mothers with GD were studied. Macrosomia was defi ned as

BW>90th percentile or > 4000 g, being SGA as BW and/or BL<10th percentile, and normal ponderal

index (PI=BW/BL3) as 2.32-2.85g/cm3. Collected data was compared to data on general population

from national perinatal informational system for a 8-year period.

Results. Eighty-eight newborns (54 boys, 34 girls) of mothers with GD, GA 38±1 weeks, BW 3473±816

g, BL 51±4 cm, and HC 35±6 cm were admitted for evaluation. Twenty-six (29.5%) were born prema-

turely. Their birth measures were not signifi cantly different compared to general population. Macroso-

mia was observed in 36 (40.1%) and microsomia in 5 (5.7%) newborns. An increased PI was observed in

11 (12.5 %) and decreased PI in 17 (19.3%) newborns. Their average Apgar scores 1 and 5 minutes after

birth were 8 and 9, respectively. 14/88 (15.9%) newborns had perinatal asphyxia. Perinatal asphyxia

was present in 6 out of 26 born prematurely.

GD was controlled by diet in 64 cases and treated with insulin in 16 cases. The average HbA1c levels

in mothers with GD were above normal (6.24%±1.07). Complications in pregnancy were present in 31

cases, among them preeclampsia in 13, spontaneous abortions in previous pregnancies in 14, treat-

ment because of infertility in 7, and other complications in 15 cases. There were signifi cantly more

premature deliveries (29.5% vs. 7.8%) in the GD group compared to general population. There were 56

vaginal deliveries, 31 caesarean sections and 1 vacuum extraction in the study group.

Hypertrophic cardiomyopathy developed in 11/47 (23.4%) of newborns of mothers with GD. Twenty-

four newborns had congenital anomalies (27% vs. 5.7% in general population), in majority of cases

cardiac and genitourinary. RDS was present in 17/88 cases (19.3%), birth injuries in 20/88 (22.7%),

hypoglycaemia in 20/88 (22.7%), hypocalcemia in 6/88 (6.8%), polycytaemia 12/88 (13.6%) and the

need for phototherapy because of hyperbilirubinemia in 34/88 (38.6%). The neurological evaluation in

the neonatal period was optimal in 60 and nonoptimal in 28 cases and US of the brain was normal in

20 and abnormal in 30 cases.

Conclusions. In comparison to general population the newborns of mothers with GD were more often

born prematurely, had more congenital anomalies, and there was a greater incidence of hypertrophic

cardiomyopathy.

28


XXX

Sergio de Marini.


Xxxx

29


NEONATAL OUTCOME IN PREGNANCIES COMPLICATED BY GESTATIONAL DIABETES MELLITUS.

Emilja Juretić1, Marcela Ilijić Krpan1, Dunja Anzulović2, Josip Juras3, Iva Kuliš1, Iva

Rukavina1.

1Department of OB/GYN, Division of Neonatology. 2Division of Anaesthesiology and Intensive Care, 3Department of

OB/GYN. Clinical Hospital centre Zagreb. Medical Faculty Zagreb, Croatia

Background. Gestational diabetes mellitus (GDM) is a condition in which women without previously di-

agnosed diabetes exhibit high blood glucose levels during pregnancy. Diagnose is obtained by 75g/2h

oral glucose tolerance test. GDM poses a risk for mother and child, related to high blood glucose levels

and its consequences. The main risks GDM imposes on the baby are growth abnormalities, linked to

higher rate of Caesarean section (SC) and delivery trauma, and chemical imbalances after birth.

Objective. To determine the impact of gestational diabetes on neonatal complications compared to

healthy pregnancies.

Study design. We retrospectively analyzed GDM pregnancies from 10-year period, delivered in our

hospital, and compared the data to similar number of healthy pregnancies (Control group, C). A total of

3396 newborns from singleton pregnancies were enrolled in the study. Analyzed variables in newborns

were: preterm birth, SC, birth weight, neonatal macrosomia (≥4000 g), perinatal asphyxia, transitory hy-

poglycaemia, transitory tachypnoea, RDS, perinatal infection, hyperbilirubinaemia, cephalhaematoma,

clavicular fracture, brachial plexus paresis, and congenital malformations.

Results. The statistically signifi cant difference was found in following variables: preterm birth (GDM

14.5%, C 6.87%, p<0.001), rate of SC (GDM 36.9%, C 16.8%, p<0.001), birth weight (GDM 3500±699g,

C 3362±762g, p<0.001), neonatal macrosomia (≥4000 g) (GDM 23.8%, C 15.4%, p<0.001), perinatal

asphyxia (GDM 5.5%, C 1.8%, p<0.001), transitory hypoglycaemia (GDM 3.5%, C 0.3%, p<0.001), RDS

(GDM 1.0%, C 0.4%, p=0.024), hyperbilirubinaemia (GDM 17.3%, C 12.0%, p<0.001), and congenital

malformations in total (GDM 4.2%, C 2.8%, p=0.032).

The following variables: transitory tachypnoea, perinatal infection, cephalhaematoma, clavicular frac-

ture, and brachial plexus paresis, did not differ signifi cantly between groups.

Conclusion. GDM does not only bear higher risk for neonatal complications linked to advanced baby

growth and chemical imbalances, but also for preterm birth, perinatal asphyxia, RDS and congenital

malformations. No signifi cant difference between the groups regarding birth trauma is probably due

to higher rate of SC in GDM group. With fi rmer blood sugar control may be possible to avoid some of

adverse neonatal outcomes in GDM pregnancies.

30


GDM: THE ROLE OF THE PLACENTA AND BEYOND

Gernot Desoye.


Xxxx

SPECIAL LECTURE

31


DALI – A EUROPEAN EFFORT TO PREVENT GDM?

Gernot Desoye.


Europe is facing a rapidly growing threat from Type 2 diabetes (T2D), which is undoubtedly associated

with an unhealthy diet and a more sedentary lifestyle. Evidence is accumulating that GDM may play a

role in this process. Thus it provides a signifi cant opportunity for preventing future T2D. Not only is GDM

prevalence on the rise, but intrauterine exposure to hyperglycaemia predisposes the offspring to diabe-

tes and obesity. Another putative contributing factor is low vitamin D status, which is also increasing in

prevalence and may have causal links with both obesity and decreased glucose tolerance.

The overall aim of the DALI project funded by the European Commission is to identify the best available

measures to prevent GDM in an ongoing pregnancy. Additional aims are 1) to provide a cost-benefi t

calculation of GDM prevention for health care systems, 2) to establish the current status of GDM across

Europe and facilitate the adoption of a single diagnostic approach, and 3) to establish a pan-European

cohort of mother-offspring pairs for future analyses with a central biobank and data base. The consor-

tium comprises 11 partners from academia and 2 SMEs (small-medium-enterprises) from 11 European

countries.

For the main purpose, a randomised controlled trial will be conducted in 10 European countries. In each

country, 88 women (BMI ≥ 29) will be recruited before 12 weeks of pregnancy. Women will be followed

for about 7 months (from 12 weeks of pregnancy until delivery). The women will be randomised to life-

style intervention, vitamin D intervention or no intervention at all.

Women receiving the lifestyle interventions (physical activity, diet or a combination of these two) will

have personal contact with a lifestyle coach as soon as possible after randomisation. All coaches are

trained in motivational interviewing techniques. The same coach will deliver the nutrition and/or physical

activity interventions. In the intervention programme, one-to-one contacts will be offered, along with

telephone follow-up. Women receiving the vitamin D intervention will receive a daily dose of either 500,

1000 or 1500 IU per day, depending on the dose that will result in the best blood levels as determined

in a pilot study.

The main outcome measures of the trial are: fasting blood glucose, weight gain during pregnancy and

insulin sensitivity.

1) The group comprises: A. van Assche (BE), R. Corcoy (ES), P. Damm (DK), G. Di Cianni (IT), G. Desoye

(AT), R. DeVlieger (BE), F. Dunne (IR), D. Hill (CH), A. Kautzky-Willer (AT), M. Klemetti (FI), A. Lapolla (IT),

E. Mathiesen (DK), P. Rebollo (ES), D. Simmons (UK), F. Snoek (NL), M. Tikkanen (FI), D. Timmerman

(BE), M. van Poppel (NL), E. Wender-Ożegowska (PL), A. Zawiejska (PL).

FREE COMMUNICATIONS

32


GESTATIONAL DIABETES: WOMEN’S CONCERNS, MOOD, QUALITY OF LIFE AND TREATMENT SATISFACTION

G Trutnovsky, M Dorfer, E Magnet, Thomas Panzitt.


Objective. To explore qualitatively motivational factors and concerns of women treated for GDM.

To examine prospectively health related quality of life (HRQL), mood state and treatment satisfaction.

To examine differences between treatment regimes.

Research Design and Methods. Observational cohort study of 27 diet-treated and 18 insulin-treated

women with GDM. A semistructured interview was conducted right after diagnosis. The WHO Qual-

ity of Life questionnaire (WHO- QOL- BREF), the Multidimensional Mood State Questionnaire (MDBF),

and the Diabetes Treatment Satisfaction Questionnaire (DTSQ) were administered repeatedly until late

pregnancy.

Results. Qualitative analysis of the initial open interviews identifi ed fi ve dominant themes The majority

of women showed high motivation and willingness for treatment in order to do “the best for the baby”.

Treatment satisfaction was generally high with no signifi cant changes over time. However, there was a

signifi cant reduction of QOL and the bipolar dimensions ”well-being” and “nervosity” from fi rst assess-

ment until late pregnancy. There were no signifi cant differences between treatment groups.

Conclusions. Acknowledgment of women’s concerns and comprehensive information may reduce

prolonged psychological distress, and improve treatment motivation and compliance.

33


SHORT-TERM NEONATAL OUTCOME IN DIABETIC VERSUS NON-DIABETIC PREGNANCIES COMPLICATED BY NONREASSURING FETAL HEART RATE TRACINGS.

Philipp Reif, Thomas Panzitt, Franz Moser, Bernhard Resch*, Josef Haas, Uwe Lang.

Department of OB/GYN. *Division of Neonatology. Department of Pediatrics Medical University of Graz, Austria.

Objective. Whether pathologic changes in fetal heart rate tracings during labor indicate the risk of fetal/

neonatal acidosis in the same way and to the same extent in deliveries of diabetic versus non-diabetic

women is not well known. Do fetuses of diabetic mothers cope less effectively with fetal distress than

those of non-diabetic women in labor? In this study we analysed the impact of nonreassuring fetal heart

rate patterns and suspected fetal distress during active labour on the short-term neonatal outcome in

diabetic compared to non-diabetic mothers.

Materials and Methods. In a retrospective cohort-study we compared the short-term neonatal out-

come including Apgar score at 5 minutes, arterial und venous umbilical cord blood pH in 57 deliver-

ies of women with gestational diabetes and 114 healthy controls (matched pairs). The patients were

selected out of all deliveries (n=590) with suspected fetal distress during active labor and one or more

fetal scalp pH sampling performed at the Department of Obstetrics and Gynecology, Medical University

Graz, Austria during the years 2008-2009.

For statistical evaluation we used Wilcoxon-U-test, t-test as well as Pearson’s Chi-square-test and

Fisher’s exact test.

Results. Arterial umbilical cord blood ph was signifi cantly lower in the diabetic group (7.215 vs. 7.250,

p=0.007). Venous umbilical cord blood pH did not show any difference. Apgar scores at 5 minutes

were similar in the diabetic and the control group (Apgar score ≥ 8: 96.5% vs. 95.6%, p=1.000). Fetal

scalp blood pH sampling showed a trend to lower intrapartum pH values in the diabetic group (pH >

7.25: 14.1% vs. 7.1%, p=0.166).

Conclusion/Discussion. Newborns of women with gestational diabetes and nonreassuring fetal

heart rate tracing during labour have a moderately elevated risk of peripartum acidosis without conse-

quences on neonatal postpartum adaption. Thus, no general changes in obstetric management seem

to be necessitated.

Special attention to pathological changes in fetal heart rate patterns and to the more rapid decline in

fetal pH during periods of fetal distress may be warranted in women with gestational diabetes during

active labour. More frequent fetal scalp pH testing to rule out clinically relevant fetal acidosis needs to

be discussed.

34


THE INFLUENCE OF GLYCEMIA CONTROL ON INCIDENCE OF PREECLAMPSIA/ ECLAMPSIA IN GDM PREGNANCIES.

Vito Starčević, Dunja Anzulović, Josip Juras, Mislav Herman, Jozo Blajić.

Department of OB/GYN. Hospital Medical Centre Zagreb. School of Medicine, University of Zagreb, Croatia.

Inadequate regulation of glycemia in women with gestational diabetes mellitus is associated with an

increased risk of pre-eclampsia and other complications through pregnancy. The GDM subjects who

developed pre-eclampsia were signifi cantly younger, had a higher nulliparity rate, were more obese,

and gained signifi cantly more weight during pregnancy.

Aim of the study. A retrospective analysis of prospectively collective data of 1354 in GDM pregnant

women through period between 2001 to 2010 was performed to determine the rate of pre-eclampsia.

The aim of the study is to analyze the incidence of preeclampsia and other risk factors in GDM pregnant

women.

Study design and methods. During the period 2001-2010, we followed up 1354 consecutive un-

selected pregnancies in women with gestational diabetes mellitus. Glycemic control was assessed

by HbA1c at the time of diagnose. Pre-eclampsia was defi ned as RR>140/90 mmHg combined with

albuminuria of >0.3 g/L. The occurence of pre-eclampsia was also associated in a control group com-

prising 2387 unselected pregnant women.

Results. Pre-eclampsia developed in 35 women (2,6%) with gestational diabetes and in 27 women

(1,1%) of the controls; χ2=11,119 (CI 95% 0,57 – 2,56), p<0,001; RR = 2,29 (CI 95% 1,39 – 3,76) p<0,001.

After adjustment by logistic regression, both the FBG and PBG and their changes during pregnancy

remained signifi cant predictors for pre-eclampsia. The odds for pre-eclampsia increased by a factor

of (1.2) for each 1 mmol/L increment in initial FBG level and PBG level, and decreased by factor of (0.8)

for each 1 mmol/L decreased of FBG or PBG level achived during pregnancy.

Conclusion. The results suggest that in GDM pregnant women had an independent and signifi cant

association between GDM and pre-eclampsia. The occurrence of pre-eclampsia in these women is

closely related to the plasma glucose level at GDM diagnosis and how well the maternal glucose level

is controlled. A model based on clinical data yielded predicted the development of pre-eclampsia in

women with GDM.

35


THE IMPACT OF PREPREGNANCY BMI AND WEIGHT GAIN DURING PREGNANCY ON PREGNANCY OUTCOME AMONG WOMEN WITH GDM.

Josip Juras, Marina Ivanišević, Mislav Herman, Marina Horvatiček, Dunja Anzulović.


Introduction. Obesity is one of risk factors for impaired glucose metabolism, preeclampsia and ad-

verse pregnancy outcome. Prepregnancy body mass index correlates with perinatal outcome, but

weight gain during pregnancy seems to have an important infl uence on birth weight.

Aim. The aim of this study was to explore weather prepregnancy BMI or weight gain during pregnancy

had bigger infl uence on perinatal outcome among GDM women vs. controls.

Materials and methods. This is a historical cohort study. The data of one decade period till 2010 from

our clinic was analyzed. It included 3741 singleton pregnancies. Women were divided into 4 subgroups

according to their diagnosis and prepregnancy BMI.

Results. Both BMI and maternal weight gain were positively correlated to neonatal birth weight, but

weight gain had bigger correlation coeffi cient than BMI (r=0.256, r=0.158; p<0.001, respectively). There

was a statistically signifi cant difference between subgroups in birth weight and ponderal index. The

biggest birth weight and ponderal index had children form GDM mothers with BMI ≥25, the smallest

were in control group with BMI <25. The results of standard multiple linear regression showed that

maternal weight gain had higher infl uence to birth weight than BMI (R2=0.011, ΔR2=0.114; p<0.001).

GDM women with BMI ≥25 had the highest rate of macrosomic neonate (30.1%) among other groups

(χ2=103.053; p<0.001). The rate of preterm birth was likewise highest (9.2%, χ2=12.92; p=0.005). Ac-

cording to greater weight gained women had macrosomic neonate more often. The likelihood ratio for

women who gained 10-16 kilos was 0.895, but with 20-24 and 24-30 kilos gained rates were 1.577 and

2.965, respectively. Having GDM there is 1.61 RR of having macrosomic neonate in relation to control

group. GDM women with BMI ≥25 had 1.49 RR (95% CI 1.41 – 1.85; p<0.001) for macrosomic child in

relation to GDM women with BMI <25 (95% CI 1.22 – 1.81; p<0.001).

Conclusion. Considering BMI and weight gain as predictor parameters for perinatal outcome it can be

concluded that weight gain has higher predictive value compared to BMI. Women with larger BMI and

weight gain have more adverse perinatal outcome and is getting poorer as BMI and weight continue

to rise.

36


PREGNANCY OUTCOME IN PATIENTS WITH OPTIMALLY TREATED GESTATIONAL DIABETES MELLITUS.

Mislav Herman, Marina Ivanišević, Josip Juras, Marina Horvatiček, Jozo Blajić.


Pregnancy is characterized by insulin resistance and hyperinsulinemia, thus it may predispose some

women to develop diabetes. The resistance stems from placental secretion of diabetogenic hormones,

as well as increased maternal adipose deposition, decreased exercise, and increased caloric intake.

These and other endocrinologic and metabolic changes ensure that the fetus has an ample supply of

fuel and nutrients at all times. Gestational diabetes occurs when pancreatic function is not suffi cient

to overcome the insulin resistance created by changes in diabetogenic hormones during pregnancy.

The term “gestational diabetes” has been used to defi ne women with onset or fi rst recognition of ab-

normal glucose tolerance during pregnancy. However, in 2010, the International Association of Diabetes

and Pregnancy Study Group (IADPSG recommended a change to this terminology. In this system,

diabetes diagnosed during pregnancy is classifi ed as overt or gestational.

The rationale for this change is that an increasing proportion of young women have overt but as yet

unrecognized type 2 diabetes due to the increasing prevalence of obesity and lack of routine glucose

screening/testing in this age group.

Several adverse outcomes have been associated with diabetes during pregnancy: preeclampsia, hy-

dramnios, fetal macrosomia, fetal organomegaly, birth trauma, operative delivery, perinatal mortality,

neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypo-

calcemia, erythremia).

There are also potential long-term consequences to the infant, such as development of obesity and

diabetes during childhood, impaired fi ne and gross motor functions, and higher rates of inattention and/

or hyperactivity.

For the mother with gestational diabetes, there is a 10 percent likelihood of overt diabetes mellitus im-

mediately after the index pregnancy. The likelihood of developing overt diabetes in the years following

the pregnancy has been estimated to be as high as 40 percent within 20 years.

Identifying women with GDM is important because appropriate therapy can decrease maternal and

fetal morbidity, particularly macrosomia. An effective treatment regimen consists of dietary therapy, self

blood glucose monitoring, and the administration of insulin if target blood glucose concentrations are

not met with diet alone.

37


THE INTERDISCIPLINARY CARE OF DIABETES IN PREGNANCY.

Gyorgy Vajda1, Z Bagosi2, T Oroszlán2, B Gasztonyi2.

Dept. Ob&Gyn1, Dept. Int.Med 2. Zala County Hospital. Zalaegerszeg, Hungary.

The frequency of occurrence of diabetes in pregnancy has risen in the last few decades. We have

experienced a similar tendency in Zala County recently. This fact established the base of necessity

in organizing an interdisciplinary work team for the better management. On the basis of this, two of

our internists and neonatologists with diabetological skills and two of our obstetricians with skills for

ultrasound were involved. With the help of their team work the recognition rate has improved, and with

our care the extremely high birth weight rate has decreased, so we could introduce our preconception

care.

Out of 1283 normal deliveries, 139 combined with GDM, which means 10.8%. The preterm birth rate

reached 14.83%, and in our care group there was no major anomaly. Our data suggests that the mul-

tidisciplinary diabetes care gave the chance to a better outcome.

38


DELAYING THE DELIVERY AFTER PREMATURE RUPTURE OF MEMBRANES: COST – BENEFIT ANALYSIS

Alenka Višnić¹, Snježana Škrablin², Davor Hulina³.

Department of OB/GYN, Hospital of Pakrac1, Department of OB/GYN. Hospital Medical Centre Zagreb. School of


Premature rupture of membrane (PROM) happenes, by definition, before 37th week of gestation.

Incidence is 3% of all pregnancies. It causes signifi cant perinatal morbidity and foetal death. Prolonging

the PROM – delivery interval (delivery delay = DD) is an usual practice to achive optimum of newborn

maturation. Such a procedure, however, increases the risk of neonatal complications. Purpose of this

study is to determine cost-benefi t ratio comapring advatages and disadvantages of delivery delay in

such cases.

We analysed, retrospectively, a number of 501 pregnancies where the PROM occurred, in time period

of four years (01/1/2007 – 12/31/2010). Pregnancies were divided in groups according a) gestation

period of PROM ( PROM before 24th week, PROM between 24th and 32nd of gestation and a group

where PROM occurred after 32nd week of gestation). The same pregnancies were divided by b) the

term of delivery in a group with a delivery before 32nd week of pregnacy, and a group whwre the de-

livery occurred after 32nd week of gestation with subgroups where division was based on c) delivery

delay (DD less than a day, DD 24 – 48 hrs, DD 2 – 5 days, DD more than 5 days). Newborns outcome

was analysed considering body weight, pulmonary complications, neurological complicatins

and perinatal infections. All those parameters were correlated considering group division of preg-

nancies and compared. The number of healthy newborns was noted and related with key features

for each group of pregnancies. Body weight is in direct positive correlation with the term of delivery and

not affected by the gestation period of PROM or delivery delay . In the group of newborns delivered in

a period between 24th and 32nd gestation week (N=207) range of weight is 490 – 1520 g (M=1256,32;

SD=387,081). In a group delivered after 32nd week of gestation (N=272) body weight ranges between

730 and 2860 g (M=2322,83; SD=510,646).

Pulmonary complications differs signifi cantly regarding gestation period of PROM. In a groups with

PROM before 32nd gestation week the incidence of pulmonary complications was 38,6%. In a grup

where PROM occurred after 32nd week of gestation that incidence was 5,8%. Delivery delay affected

the incidence of pulmonary complications : in the groups with the delay less than 5 days that incidence

was 14,41%, but with delaying the delivery more of 5 days incidence increases up to 25,4%. Term of

delivery didn’t have an impact on pulmonary complications. Neurological complications are related to

delivery delay. We noted a 33,3% incidence in groups with DD less than 5 days. If the delivery delay is

prolonged more then 5 days icidence increases to 61,9%. Neurological complications are affected by

the term of delivery also. In groups of newborns delivered before 32nd gestation week the percentage of

nerological complications noted was 48,1%, but this percentage decreased to 31,5 if delivery was after

32nd week of gestation. Perinatal infection was found positively correlated with delivery delay. In groups

with DD less than 5 days we found 56,3% of infections but, if delivery delay was prolonged more than

5 days, infections increased up to 70,1%. Gestation period of PROM affected the incidence of perinatal

infections: the earlyer PROM occures, the higher the incidence was observed. 58,9% of infections in

groups with gestation period of PROM up to 32 weeks, and a decrease of incidence to 42% if PROM

took a place after that time. The relative number of healthy newborns delivered is in a negative cor-

relation with gestation period of PROM: 13,3% in groups with PROM before 32nd gestation week and

28,9% in a group with PROM occurrance after that time, as it is wit the delivery delay: 17,8% with DD

less than 5 days, and 3,6% if delivery was delated more than 5 days. The signifi cance of our observa-

tions was calculated by „p“ value as follows: p<0,001 observing body weight differences; p=0,0186 for

pulmonary complications; p<0,001 in case of neurological complications differences observed, and

p<0,003 for observed perinatal infections. The difference in numbers of healthy newborns delivered

were signifi cantly different regarding gestation period of PROM and delivery delay with p value less

than 0,001. Inevitable conclusion is that delivery delay after premature rupture of membranes does not

allways produce a benefi t for newborn child. There is a point in time when the benefi ts meet negative

consequences of delivery delay. That point is still to be discovered.

39


P16/KI-67 DUAL-STAINED CYTOLOGY TESTING MAY PREDICT POST-PARTUM OUTCOME IN PATIENTS WITH ABNORMAL PAP CYTOLOGY DURING PREGNANCY.

O Reich.


40


DIAGNOSTIC RANKING WEIGHTS AS SUPPORTING SYSTEM IN TERTIARY FETAL ANOMALY SCREENING CENTER.

Nenad Veček, Branko Radaković, Tomislav Župić, Davor Petrović, Snježana Škrablin.


Key words: malformed fetus, fetal malformation, prenatal diagnosis, autopsy

Objectives. To compare autopsy fi nding with prenatal sonographic fi ndings of malformation in tertiary

fetal anomaly screening center, in order to evaluate degree of agreement between US and pathological

diagnosis according to proposed diagnostic ranking weights.

Methods. In this prospective study, 29 autopsies between 2007 and 2010 were considered. Diagnos-

tic weights were determined on the basis autopsy fi nding. According the number and distribution of

malformations four diagnostic weights (DW) were created. A: fetus with single simple malformation, B:

fetus with single complex malformation, C: fetus with 2 or more simple malformations and D: fetus with

2 or more complex malformations and simple malformations. In comparison of US fi ndings and autop-

sies, only a total total agreement between US and autopsy fi ndings were considered as comprehen-

sively assessed malformed fetuses. Concordance in prental and postnatal diagnosis of malformation

was considered as correctly diagnosed malformation, otherwise the malformation was cosidered as

undiagnosed. The frequency of comprehensively assessed fetuses were, according to the diagnostic

ranks were calculated. The diffrences were test by Chi-square test with α<0.05.For each weigh rank

undiagnosed malformtions were listed and the mean number of malformtion is calculated.

Results. Of total 29 fetuses, 16 of them (55.1%) were comprehensively assessed, 11/11 (100%) A-DW,

½ (50%) B-DW, 3/10 (30%) C-DW and 1/6 (16.6%) D-DW (χ2,p=0.002). Of 102 malformations, 45 of

them (55.88%) were correctly diagnosed. In B weighted fetusus of 5 malformations, 2 (40%) were not

diagnosed correctly (truncus arteriosus communis and VSD). In C weighted fetuses from 42 malforma-

tions, 18 (42.85%) were not diagnosed 2 maior (encephalocoele and lung hypoplasion) and 16 minor:

facial- 4 cases chelopatashysis, 4 cases of subtle fi st anomalis, ASD, VSD, thymal aplasia, urether du-

plex, megaureter, atopic kidney, lobulated liver and subtle foot malformation. In D weighted fetuses from

44 malformations, 25 (56.81%) were not diagnosed 11 maior and 15 minor malformations. List of maior

malformation consistes of: 2 cases of anal atresia, fi bular and radial agenesis, hypoplasio and aplasio

of lungs, meningomyelocoele, AV canal (4). List of minor malformations consisted of 4 cases of genial

defects (bilateral gonadal agenses and 2 cases aplasia external sexual organs), 3 cases subtle palmar

defects, 3 cases of facial defects (bilateral anotia and mandibular hypoplasia), 2 cases of thymal defects

(hypoplasia nd ectopia), rectovaginal fi stula, unilateral renal agensis. Mean number of malformations

according to weight rank: A=1, B=2.5, C=4.2, D=7.3.

Conclusion. This study showed solid degree of agreement between US and autopsy fi ndings in fe-

tuses with prenatal ultrasonic diagnosis of malformations and proved relations between diagnostic

weights and diagnostic accuracy. We recommend the use of proposed diagnostic weights as support

system in tertiary fetal anomaly screening center.

41


BMI AND GDM AS PREDICTORS OF ADVERSE PREGNANCY OUTCOME IN SLOVENIAN POPULATION IN THE YEARS 2005-2009.

L Steblovnik, I Verdenik, M Tomažić, Tanja Premru Sršen.


42


INTRODUCTORY LECTURES – HYPERTENSIVE

DISORDERS

MANAGEMENT AFTER SEVERE FORMS OF PREECLAMPSIA/ECLAMPSIA/HELLP SYNDROM.

Mila Červar Živković.


The concept of diagnostic and treatment in patients with the history of severe complications of hyper-

tensive disorders in pregnancy used in the Unit for hypertensive disorders of Dept. Ob. Gyn., Medical

University Graz will be presented.

43


NEONATAL HYPERTENSION.

Gregor Nosan.

Department of Neonatology, Division of Pediatrics, University Medical Centre Ljubljana, Slovenia.

Abstract. Hypertension is defi ned as systolic and/or diastolic blood pressure ≥ 95th percentile based

on normative data for age, gender and weight. The incidence of neonatal hypertension is 0.2 to 3% of

all neonates admitted to neonatal intensive care units, occurring more frequently with concurrent con-

ditions like indwelling umbilical artery catheter or broncopulmonary dysplasia. A focused history and

a careful diagnostic evaluation should lead to determination of the underlying cause of hypertension

in most infants. Treatment consists of identifying and correcting any underlying cause of hypertension

and when indicated, initiating pharmacologic therapy to lower blood pressure. Depending on the un-

derlying etiology, most infants will resolve hypertension over time, although a small number may have

persistent BP elevation throughout childhood.

44


HYPERTENSION AND PREGNANCY OUTCOME (ONE YEAR EXPERIENCE).

Nemeth Gabor, Zita Gyurkovits, Orvos Hajnalka, Bito Tamas, Attila Pal.


Introduction. Hypertension during pregnancy is still a common and severe, potentially divastating

complication. Although, ideally the diagnosis of that condition should involve the use of biomarkers that

refl ect the underlaying pathophysiology of the disease process, the lack of suitable clinical assays has

forced the clinicians to diagnose the condition based solely on the clinical presentation.

Objective. To compare the impact of pregnancy-induced hypertension and chronic hypertension on

pregnancy outcome.

Results. The maternal and fetal data of pregnancies complicated with hypertension admitted between

the 1st of January 2009 and 31st of December 2009 to the Department of Obstetrics and Gynaecol-

ogy, University of Szeged, were analyzed by the authors. In this period 137 preeclamptic patients were

admitted to the department. Int he 24% of the all cases vaginal and int he 76% Cesarean section were

performed. The majority of the Cesareans was indicated because of intrauterine distress (27,8%). In

6.6% of all the cases HELLP syndrome was developed, in one case in the puerperial period. In 12.4%

diabetes and in 10.2% was in the history. The 10.2% of the cases was occured after using assisted

reproductive techniques.

Conclusions. In our study population, hypertension during pregnancy was associated with signifi -

cantly increased morbidity and mortality rates. Women with chronic hypertension are at greater risk for

adverse outcome than those with pregnancy-induced hypertension. Hypertension during pregnancy

remains a disease begging for supportive biological measures linked to the underlying pathophysiology

of the disease, and more studies needed to move u sin the right direction toward this goal and to the

improvement of maternal and fetal mortality and morbidity rate.

INVITED OBSTETRIC LECTURES

45


PREGNANCY OUTCOME IN WOMEN WITH PREVIOUS PREECLAMPSIA: A 5-YEAR FOLLOW UP.

C Stern, D Ulrich, Mila Červar Živković.


Hypertension is a common medical disorder in pregnancy and preeclampsia is a severe complication,

affecting mother and fetus. Women in pregnancy after preeclampsia have a substantially higher risk of

getting preeclampsia again.

154 pregnant women after the history of previous preeclampsia were observed in followed pregnancy

in Unit for hypertensive diseases between 2006- 2010.

Patients underwent a precise diagnostic workup for the previous disorder, including assessment of

blood coagulation function or other underlying diseases to evaluate the risk profi le. The special obstet-

ric care program with maternal and fetal outcome will be presented in the invited lecture.

46


UTERINE ARTERIES DOPPLER IN FIRST TRIMESTER.

B Sajina Stritar, M Drušković, N Tul Mandić, Tanja Premru Sršen.


47


FIRST TRIMESTER PREGNANCY SCREENING: PLGF, PAPP-A, PP-13, UTERINE ARTERY DOPPLER AND MATERNAL CARACTERISTICS IN THE PREDICTION OF HYPERTENSIVE DISORDERS.

Giuseppina D’Ottavio, Matteo Ceccarello, Giovanni Di Lorenzo, Vera Cecotti.

Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health – IRCCS “Burlo Garofolo” –

Trieste, Italy.

Introduction. Hypertensive disorders in pregnancy are major causes of maternal and fetal mortality

and morbidity (1). Despite the physiopathology of these conditions is well known there is no an early

and accurate screening method as in aneuploidy. Until now the fi rst approach is based on maternal

history, in order to detect a high-risk pregnancy group.

Currently, based on combined aneuploidy screening model, there is increasing interest in the use of

multiparameter predictive tests, combining maternal history, several maternal serum biomarkers and

uterine artery Doppler velocimetry (UtA); the combination of different predictive factors covers the mul-

tiple physiopathologic pathways and improves the detection rate of the screening. Because there are

several and heterogeneous biomarkers involved in the placental dysfunction, the attention of different

research groups is focused on different biomarkers: some analytes are currently obtained as part of

aneuploidy screening (PAPP-A, ß-hCG); whereas, others have been proposed specifi cally for these

adverse pregnancy outcomes (PlGF, PP-13). So far, the predictive ability of any single one of these is

generally poor and the results of integrated models are divergent (2-4).

Objective. The aim of the present study was to examine, in an unselected population, the diagnostic

accuracy of fi rst trimester UtA Doppler velocimetry for the detection of subsequent hypertensive dis-

orders, associated with several serum biomarkers (PAPP-A, PlGF and PP-13) and maternal history, in

order to detect a high risk group of women in early term pregnancy.

Materials and methods. This is a prospective cohort study of unselected pregnant women followed

by Prenatal Diagnosis and Gynaecologic Unit of IRCCS Burlo Garofolo in Trieste. All women recruited

were followed from fi rst trimester ultrasound screening for aneuploidy to delivery with morphologic and

biometric ultrasound. We enrolled 2138 singleton pregnancy from October 2007 to April 2009 and per-

formed a combined screening test for Down syndrome between 11th-13th gestational weeks, adding

UtA Doppler evaluation in each trimester. At the moment of the fi rst ultrasound women’s anamnestic

data were collected and blood samples were obtained to dose PAPP-A,ß-hCG, PlGF and PP-13.

As outcomes we considered gestational hypertension (GH), early-onset preeclampsia (PE), late-onset

PE and PE (both early and late-onset) and compared all of them with the unaffected group.

Firstly the distribution of data was tested for normality using the Kurtosis and Skweness tests: none of

them resulted normal, so we’ve chosen the closest one to the normality. Then we analyzed the correla-

tion between all possible predictive factors (UtA PI, UtA RI, UtA Notch, NT, CRL, PAPP-A, ß-hCG, PlGF

and PP-13) and maternal characteristics in order to calculate their MoM values. MoM were calculated

on healthy women and secondly corrected on the single features that were statistically related to the

biomarkers. Using Mann-Whitney test we compared MoM of the unaffected group to every outcome, in

order to detect statistically signifi cant differences between them. Then we evaluated a bivariate analysis

regression to fi nd the linkage between our outcomes, maternal characteristics and all predictive mark-

ers and were assessed the odds ratios. We performed two different multivariate regression analysis.

In the fi rst one we included all the maternal variables and markers simultaneously, both statistically

signifi cant or not, based on Nicolaides et coworkers’ results4; so sensitivity models were calculated for

fi xed specifi city rates from the ROC curves. The second multivariate regression was performed starting

48


from the saturated model, and using the stepdown procedure, we exluded, one by one, all factors not

statistically signifi cant (p>0.05), starting from the factors with higher p values. Finally, all the variables

were dichotomized, and sensitivity models only for statistically signifi cant parameters were calculated

for fi xed specifi city rates from the ROC curves.

Results. We built one statistical model for each outcome: gestational hypertension (GH), early-onset

preeclampsia (PE), late-onset PE and PE (both early and late-onset), in order to verify the accuracy of

UtA Doppler, biochemical markers and maternal history and fi nally created the sensitivity models from

ROC curves. The best results were obtained in PE and early-onset PE models.

Using the multivariate logistic regression with all the variables (also with p>0.05):

• PE model: the sensitivity was 40, 60, 60 and 67% respectively with 95, 90, 85 and 80% of

specifi city.

• Early-onset PE model: the sensitivity was 67, 67, 75 and 84% respectively with 95, 90, 85 and

80% of specifi city.

• Using the multivariate logistic regression with stepdown procedure the results were slight worse:

• PE model: the sensitivity was 32, 40, 48 and 60% respectively with 95, 90, 85 and 80% of

specifi city.

• Early PE model: the sensitivity was 67, 75, 75 and 75% respectively with 95, 90, 85 and 80% of

specifi city.

Conclusions. The integration of maternal history with several biochemical markers and UtA Doppler

velocimetry seems to be the most appropriate approach for the establishment of an accurate fi rst tri-

mester screening test for hypertensive disorders, along the lines of the test used for Down’s syndrome.

The strength of our study was the prospect design and the use of a robust statistical methodology with

stepdown logistic regression that gives quite comparable results to other authors’ approach. Probably

the inclusion of new biomarkers will improve detection rates of the screening, by covering different

physiopathologic pathways, as shown by Kusanovic et al.: using the unbalancing of pro-angiogenic

and anti-angiogenic factors (PlGF vs s-Eng e sFlt-1), they generated a screening test with high perfor-

mance, both in term of sensitivity and specifi city (about 100 and 98% respectively) (5).

References.

1. Sibai BM. Caring for women with hypertension in pregnancy. J. Amer. Med. Ass. 2007; 298,

1566-2007.

2. Giguere Y, Charland M, Bujold E, et al. 2010. Combining biochemical and ultrasonographic

markers in predicting preeclampsia: a systematic review. Clin Chem 56: 361–374.

3. Zhong Y, Tuuli M, Odibo AO. 2010. First-trimester assessment of placenta function and the

prediction of preeclampsia and intrauterine growth restriction. Prenat Diagn 30: 293–308.

4. Akolekar R, Syngelaki A, Sarquis R, Zvanca M, Nicolaides KH. Prediction of early,

intermediat and late pre-eclampsia from maternal factors, biophysical and biochemical markers

at 11–13 weeks. Prenat Diagn 2011; 31: 66–74.

5. Kusanovic JP, Romero R, Chaiworapongsa T, et al. A prospective cohort study of the value of

maternal plasma concentrations of angiogenic and antiangiogenic factors in early pregnancy

and midtrimester in the identifi cation of patients destined to develop preeclampsia. J Matern

Fetal Neonatal Med 2009;22(11):1021–38.

49


AGGRESSIVE VERSUS EXPECTANT MANAGEMENT OF SEVERE PREECLAMPSIA IN PRETERM GESTATIONS.

Snježana Škrablin, Vesna Elveđi Gašparović, Nenad Veček, Trpimir Goluža, Alenka

Višnić.


Preeclampsia (EI) still remains the leading cause of fetal and maternal morbidity and mortality. It is

unpredictable in its onset and progression and thought to be incurable except by termination of preg-

nancy. The delivery is always appropriate therapy for the mother, but may not be so for the child if

remote from term . That’s why, in recent years, a different treatment approach with severe preeclamp-

sia remote from term has been proposed: aggressive management with immediate delivery after initial

stabilisation of patient or conservative, expectant management, until the occurrence of maternal or fetal

danger or gestational age of at least 34-36 gestational weeks.

In the present report maternal and fetal outcome of severe preeclampsia, defi ned by ACOG criteria,

remote from term will be presented. A total of 168 pregnancies cared for during a 10 year period will be

analyzed. After initial stabilization of blood pressure and initialization of the therapy that would prevent

convulsions, aggressive management was offered to 65 of pregnancies while the other 103 were man-

aged conservatively. Maternal complications and neonatal outcome between the two groups will be

presented.

50


HYPERTENSION AND NEONATAL CONSEQUENCES.

Judit Kiss.

Department of Paediatrics. University of Szeged, Hungary.

INVITED PEDIATRIC LECTURES

51


MANAGEMENT OF HYPERTENSION IN THE NEWBORN.

F Reiterer.


Abstract. Although the incidence of neonatal hypertension is rather low (0.2-3%) it may be identifi ed in

various clinical situations in the NICU. Most cases of hypertension are of renovascular origin frequently

related to an umbilical artery catheter-associated thromboembolism. An important nonrenal cause of

hypertension is bronchopulmonary dysplasia (BPD), a disease occurring mainly in extreme low birth-

weight infants in which hypertension may either result from hypoxemic episodes or and iatrogenically

due to medications like corticosteroids or methylxanthines given to treat the underlying pulmonary

conditions. Coarctation of the aorta needs to be considered in all neonates with hypertension. In any

case of hypertension a careful diagnostic evaluation including patient history, physical examination ,

laboratory and imaging studies as indicated should be performed. Once the underlying cause of hyper-

tension has been determined numerous medications are available for either intravenous therapy, oral

therapy or both, depending on the cause and the severity of the hypertension. As long term sequelae

of hypertension and antihypertensive therapies are unknown at this time management should include

closely monitoring of the infants even after their hypertension has resolved.

52


Italy

53


NEONATAL OUTCOME OF PREECLAMPTIC PREGNANCIES.

Snježana Gverić Ahmetašević, Ana Čolić, Sanja Anić Jurica.

Department of paediatrics. Hospital Medical Centre Zagreb. School of Medicine, University of Zagreb, Croatia.

Objective. The purpose of this study was to compare neonatal outcomes of pregnancies with pre-

eclampsia according to birthweight (BW) and the number of nucleated red blood cells.

Study design. We analysed newborns who were born from pregnancies with preeclampsia during

eight years in our Hospital center. The women who had premature rupture of membranes or some

other disorders were excluded from the study, as well as newborns with malformations and chromo-

somal anomalies.

Apgar score in 1st and 5th minute, hypo/hyperglycaemia in fi rst days of life, respiratory support, infec-

tions, brain ultrasound fi ndings at discharge, and neonatal outcome were analysed. The newborns

were divided into 2 groups : small for gestational age and appropriate for gestational age. We also

compared newborns with and without nucleated red blood cells as the mark of chronic hypoxia.

Results. In this study there were no signifi cant differences between newborns according to birth-

weigth. But, we found signifi cantly low BW, GA, Apgar score in the newborns with higher number of

nucleated red blood cells also signifi cantly higher rate of infections, abnormal ultrasound fi ndings and

abnormal neonatal outcome.

Conclusion. The newborns with the higher number of nucleated red blood cells showed signifi cantly

higher morbiditiy than the newborns without nucleated red blood cells. The chronic hypoxemia in

pregnancies with preeclampsia with higher number of nucleated red blood cells as one of the major

signs, is morbidity carrier.

54


THROMBOPHILIA SCREENING IN WOMEN AFTER PREECLAMPSIA/ECLAMPSIA/HELLP-SYNDROM. A 5 YEARS FOLLOW-UP.

E Weiss, F Prüller, Mila Červar Živković.


FREE COMMUNICATIONS

55


ENDOTHELIN-1 STIMULATES PROLIFERATION OF FIRST TRIMESTER TROPHOBLASTS VIA THE A- AND B- TYPE RECEPTOR AND INVASION VIA THE B-TYPE RECEPTOR.

Mila Červar Živković1, M Dieber Rotheneder1, S Barth1,4, T Hahn1,3, G Kohnen2, B

Huppertz3, Uwe Lang1, Gernot Desoye1.

1Department of Obstetrics & Gynaecology. 3Institute of Cell Biology, Histology and Embryology, 4Institute of

Biochemistry and Molecular Biology. Medical University of Graz, Austria. 2Department of Pathology, Western

Infirmary, University of Glasgow, UK.

Objective. To test the hypothesis that ET-1 effects are mediated by different receptor subtypes (ETRs:

ETR-A, ETR-B).

Methods. The location of ETRs in trophoblast cell columns (weeks 6-12) was investigated by immuno-

histochemistry and autoradiography. Trophoblasts were isolated from fi rst trimester human placentas

and proliferative and invasive subpopulations separated using an integrin α6 antibody. Cells were incu-

bated for 24h with 10μM ET-1 and different ETR-antagonists: PD142893 (unselective), BQ-610 (ETR-A)

and RES-701-1 (ETR-B). After ETR downregulation by antisense oligonucleotides, proliferation (thymi-

dine incorporation, protein synthesis) and invasion (Matrigel invasion) were measured. ETR expression

in isolated cells was analyzed by Western blotting and sqRT-PCR.

Results. Both ETRs are expressed in both subpopulations in the cell column with predominance of

ETR-A in the proximal part and proliferative subpopulation, whereas ETR-B is present at similar levels

in both subpopulations. These results were confi rmed at the mRNA level. ET-1 increased proliferation

(max 267% of control) and invasion (max 288% of control) of fi rst trimester trophoblasts. The mitogenic

ET-1 effect was inhibited (p<0.05) by 40-80% with each receptor antagonist, and by 44% and 40%, re-

spectively, by ETR-A and ETR-B antisense-oligonucleotides. The invasion promoting effect was almost

completely blocked in the presence of the ETR-B antagonists.

Conclusion. The effect of ET-1 on cell proliferation in fi rst trimester trophoblasts is mediated by both

ETRs, while its effect on invasion is mediated predominantly by ETR-B. These effects are in line with

receptor subtype location.

56


ENDOTHELIN/ENDOTHELIN RECEPTOR SYSTEM IS UPREGULATED IN PREECLAMPSIA WITH OR WITHOUT FETAL GROWTH RESTRICTION IN CONTRAST TO GESTATIONAL DIABETES.

M Dieber Rotheneder, S Beganovic, M Fellner, Uwe Lang, Gernot Desoye, Mila

Červar Živković.

Department of Obstetrics & Gynaecology, Medical University of Graz, Austria.

Introduction. In addition to its vasoregulative function, in the human placenta endothelin-1 (ET-1) also

regulates cell differentiation, proliferation, invasion and apoptosis. ET-1 effects are signaled through two

receptor subtypes ETR-A and ETR-B. We tested the hypothesis that the expression of ET-1 and ETRs

is altered in preeclampsia (PE), fetal growth restriction (FGR) and in gestational diabetes (GDM) and dif-

fers between early (gestational week ≤ 34) and late (GW >34) third trimester pregnancies.

Methods. The study included women (GW 28-41) with PE (blood pressure >140/90 mmHg, protein

>300mg/24hrs; n=16), with FGR (<10th birthweight centile and pathological umbilical blood fl ow; n=7)

and PE+FGR (n=5) and with GDM (±insulin treatment n=21), as well as age-matched controls (n=20).

ET-1, ETR-A and ETR-B mRNA and ETR-A and ETR-B protein were quantifi ed in placental tissues by

real-time PCR and immunoblotting.

Results.

Table 1: mRNA expression in third trimester pregnancies:

Fold changes versus age-matched controls (p-values)

GW ≤ 34 GW > 34

ETR-A ETR-B ET-1 ETR-A ETR-B ET-1

PE2.6

(0.04)

3.0

(0.01)

3.5

(0.01)

0.6

(0.05)

2.0

(0.02)

0.4

(0.05)

PE+FGR5.1

(0.05)

3.4

(0.04)

6.9

(0.003)- - -

FGR n.s n.s.3.8

(0.02)

0.6

(0.05)n.s. n.s.

GDM - - -0.5

(<0.001)

0.8

(0.05)

0.4

(<0.001)

-: not determined, because no material available, n.s.: not signifi cant

In early third trimester pregnancies ETR-A protein was upregulated (+26%) only in PE. There were no

changes in ETR-B protein. In late third trimester pregnancies ETR-A (-17%) and ETR-B protein (-33%)

were downregulated in GDM. ETR-B protein was also downregulated in FGR (-23%) and PE (-35%).

Discussion. The upregulation of the ET/ETR system in PE is correlated with the severity of the disease:

mild-late<severe-early<PE+FGR). The ET/ETR system is downregulated in GDM.

(Grants: 12243, Jubilee Funds , Austrian National Bank and Kulturamt Stadt Graz)

57


INDIVIDUAL TREATMENT OF ANTIPHOSPHOLIPID SYNDROME IN PREGNANCY.

K Mayer Pickel, M Mörtl, W Schöll, C Stern, Uwe Lang, Mila Červar Živković.


Introduction. The antiphospholipid syndrome (APLS) is an autoimmune disease, characterized by

vascular thrombosis, pregnancy loss and presence of antiphospholipid antibodies in maternal circula-

tion. A very rare form of APLS, catastrophic antiphospholipid syndrome (CAPS) is triggered by preg-

nancy, infection and surgery and presents a life-threatening condition with multiorgan failure.

Patients and Methods. Nine women with the diagnosis of APLS were observed in Dept. Ob. Gyn.

Graz from 2007 to 2011. All patients were treated with low weight molecular heparin (LWMH), seven

patients received 100 mg aspirin daily because of previous poor pregnancy outcome. Additionally, four

pregnant women were treated by corticosteroids, one with plasmapheresis and one with immuno-

apheresis, respectively.

Results. One pregnancy was complicated by early-onset preeclampsia and extreme IUGR at 27th

week of gestation and terminated by caesarean section, the child suffered under extreme growth re-

tardation with the neurological signs of ataxia and dyspraxia. Three patients developed CAPS and the

pregnancies were terminated by caesarean section between 27-32 weeks of gestation with the good

maternal and neonatal outcome. Five pregnancies showed no additional complications until the time

of the delivery, two of them were terminated by vaginal delivery at 37th-39th weeks, and three were

terminated by caesarean section because of suspect intrauterine asphyxia by routine control at 34th

week of gestation, two children were healthy, the third one died immediately after delivery because of a

terminal asphyxia. Eight women had a normal childbed and one developed the cerebral venous sinus

thrombosis despite of LWMH therapy.

Summary. APLS is associated with many severe pregnancy complications and should be treated in a

tertiary care by individualized, interdisciplinary management including the possibility to use a controlled

LWMH-therapy, aspirin and corticosteroids but also the other therapy options as plasmapheresis or

immunoapheresis, if necessary.

58


QUALITY OF LIFE IN WOMEN AFTER HYPERTENSIVE PREGNANCY DISORDERS.

C Stern, E Mautner, M Deutsch, K Mayer-Pickel, Uwe Lang, Mila Červar Živković.


Background. Preeclampsia/eclampsia and HELLP-Syndrome (PRE/E/H) are serious experiences in

life, changing the psychological profi le and need even more psychological treatment of affected per-

sons. In the present study the physical and mental stress in the group after PRE/E/HELLP were com-

pared with the healthy non-pregnant group.

Methods. 87 patients after PRE/E/H answered a questionnaire concerning their physical and mental

quality of life (SF-12 questionnaire for general state of health). They were divided into 4 groups according

to the type of disease: early- onset (<34.week of GA, 21%) and late-onset preeclampsia (>34. week of

GA, 31%) as well as superimposed PE (11%) and HELLP-syndrome (29%). Comparison was made with

the reference values from the SF-12 questionnaire.

Results. The negative affection of quality of mental life was signifi cant in all patients after P/E/H, after

early-onset preeclampsia (P=0,003), after late-onset preeclampsia (P=0,004) and after HELLP-syn-

drome (P=0.002). These with late-onset preeclampsia were also physically impaired (P=0.01). However,

women after superimposed PE were neither physically nor mentally hindered.

Conclusion. This study shows that women after the serious complications associated with severe

P/E/H are substantially reduced in their physical and mental quality of life. Medical care for these wom-

en at risk of adverse pregnancy outcome should provide individual and multidisciplinary management.

Parameters of health-related-quality-of-life should be involved to improve pregnancy outcome.

59


SPECIAL MANAGEMENT OF THROMBOPHILIA IN PREGNANCIES AFTER PREECLAMPSIA/ECLAMPSIA/HELLP SYNDROM.

E Steinbauer, N Weiss, F Prüller, C Stern, M Häusler, Uwe Lang, Mila Červar Živković.


Objective. The aim of the study was to analyze the maternal and fetal outcome after the use of in-

dividual prophylaxis in patients with “St. p. preeclampsia/eclampsia/HELLP syndrome or diagnosed

thrombophilia at the Department of Obstetrics and Gynecology, Medical University Graz.

Patients and methods. All patients who had been observed in the Unit for management of hyper-

tensive pregnancies between 2006 and 2010, were included in the analysis (Group 1, n=89). In the

addition, the patients found in the database PIA of the LKH Graz searching for the key word entries

preeclampsia, eclampsia, HELLP, hypertonia, SIH, IUGR and thrombophilia were included in the study

as the control (Group 2, n=209). Patient data was collected from the databases Medocs, PIA and sta-

tistically analyzed.

Results. The use of prophylaxis was 95% in patients with thrombophilia (“T+prophylaxis”) and 58%

in patients with “St. p. P/E/H”. In the subgroup “T+prophylaxis” 81% didn’t develop any disease, 5%

had mild preeclampsia, 5% severe preeclampsia and 5% suffered from HELLP syndrome. 17% of

the children of the same subgroup had IUGR and 34% were premature. In the group “St. p. P/E/

H+prophylaxis” 67% had no disease, 13% had mild preeclampsia, 21% had severe preeclampsia and

5% had HELLP syndrome. IUGR occurred in 10% and preterm birth in 5% of cases. Only 43% of the

patients in the group without prophylaxis (“St. p. P/E/H-prophylaxis”) had no disease. 18% had mild

preeclampsia, 39% had severe preeclampsia and 18% had HELLP syndrome. 3% of the children had

IUGR and 52% were premature. In the group 2, 32% of the women developed mild preeclampsia, 57%

severe preeclampsia and 19% HELLP syndrome. IUGR occurred in 32% of the cases and preterm birth

in 74%.

Only 3 patients suffered from eclampsia. An abortion was carried out once and an intrauterine fetal

death occurred four times.

Conclusion. Maternal outcome in subgroup “St. p. P/E/H+prophylaxis” was better compared to sub-

group “St. p. P/E/H-prophylaxis”, but the differences were not signifi cant. Fetal outcome didn’t differ

between the groups. Patients with thrombophilia received prophylaxis in almost every case and only

19% of this patient group had complications.

60


UTERINE ARTERY DOPPLER IN HIGH RISK PREGNANCIES; THE PREDICTION FOR MATERNAL HYPERTENSIVE DISEASES AND INTRAUTERINE GROWTH RESTRICTION (IUGR).

T Idris, S Gramm, M Häusler, Uwe Lang, Mila Červar Živković.


Introduction. Hypertensive pregnancies are associated with serious maternal and fetal complications.

The optimal management in pregnancy and the timing of pregnancy termination includes a carefully

weighing of risk-benefi t ratio for each individual patient.

Patients and Methods. 189 pregnant women with chronic hypertension and/or with the history of

some serious hypertensive pregnancy complications in previous pregnancies were observed in the

Unite for Hypertensive Pregnancies of Dept. Ob. Gyn. Graz from 2006-2010. The uterine Doppler ex-

aminations were performed at 11-14 and 20-24 weeks of gestation. The presence of bilateral uterine

notching with an increase of pulsatility index (PI) in both examinations was interpreted as pathologic.

The maternal and fetal outcomes were analysed.

Results. Pathologic uterine artery Doppler was measured in 12% of examined patients. In these preg-

nancies, 70% developed various hypertensive complications combined with an intrauterine growth

restriction (IUGR) in 50 %.

Summary. Pathologic uterine Doppler is a helpful marker for hypertensive complications and fetal

growth restriction in high risk pregnancies, but the predictive value is not higher than established in

common population.

61


THE MANAGEMENT OF CHRONIC HYPERTENSION IN PREGNANCY.

Vassiliki Kolovetsiou, C Stern, C Meyer-Pickel, D Ulrich, T Idris, Uwe Lang, Mila

Červar Živković.


Introduction. The complications of hypertensive disorders in pregnancy are a leading cause of ma-

ternal and fetal/neonatal mortality and morbidity. We propose that the specifi c management in tertiary

care hospital could decrease the high incidence of preeclampsia/eclampsia/HELLP Syndrom in preg-

nancies with chronic hypertension with or without history of preeclampsia/eclampsia/HELLP Syndrom.

Patients and Methods. The appearance of preeclampsia in 189 pregnancies with chronic hyperten-

sion with or without history of preeclampsia/eclampsia/HELLP Syndrom in previous pregnancies were

analyzed after the specifi c management in special unit for hypertensive disorders of Dept. Ob. Gyn in a

5 year period between 2006 and 2011.

Results. 44% of pregnancies with chronic hypertension developed preeclampsia, in the group of

54% women treated with methyl-dopa in 53% and in the group of 40% patients treated with calcium

antagonists in 72%. Patients with previous history of preeclampsia/eclampsia/HELLP Syndrome were

additionally treated with 100 mg aspirin and developed preeclampsia in 40%.

Conclusion. The data show a high incidence of preeclampsia in women with preexisting hyperten-

sion despite of established medication and intensive observation in high specialized unit of tertiary care

hospital.

62


A RETROSPECTIVE EVALUATION OF THE CLASSIFICATION OF HYPERTENSIVE DISEASES IN PREGNANCY AT THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, MEDICAL UNIVERSITY OF GRAZ, AUSTRIA.

Vassiliki Kolovetsiou, C Stern, T Idris, D Ulrich, C Meyer-Pickel, Uwe Lang, Mila

Červar Živković.


Introduction. Hypertensive disease is the most common maternal disorder in human pregnancy. The

disease ranges from a mild elevation of blood pressure in preexistent hypertension and pregnancy

induced hypertension (PIH), mild preeclampsia to severe preeclampsia, eclampsia and HELLP Syn-

drome. The right classifi cation of the form is necessary to assess the appropriate therapy patterns.

Methods. The medical documentation of Dept. Obstet. Gyn. of Medical University Graz was re-eval-

uated according to the documented clinic and laboratory fi ndings in medical histories of 687 patients

with the diagnosis of listed hypertensive disorders managed between 2006 and 2010.

Results. A failure classifi cation was found in 7% of all analyzed histories. The most common failures

were false positive diagnosis of HELLP Syndrome which should be classifi ed as severe preeclampsia

(11%), false diagnosis of superimposed preeclampsia (22%) and the classifi cation of an actually severe

preeclampsia as a mild preeclampsia (21%).

Conclusion. The primary detection of hypertensive disorders in pregnancy is standardized and well

integrated in the daily work of obstetrician, but the emergency situations in these patients hinder the

exact clinical classifi cation and an adequate management.

63


PERINATAL OUTCOME IN GRAVIDA OLDER THAN 35 YEARS WITH PREECLAMPSIA

Marko Vulić, Damir Roje.

Department of Obstetrics and Gynecology. University Hospital Split. Croatia.

Objective. To compare perinatal outcome in gravida older than 35 years with and without preeclamp-

sia.

Materials and methods. We conducted a retrospective study that included 626 women older than

35 years who delivered in the University Hospital Split between 01.01.-31.12.2007. Information was

taken from the maternal delivery records. Out of 626 women, 48 had and 578 had not preeclampsia.

Investigated variables were week of delivery, birth weight, Apgar score, parity and mode of delivery.

For statistical analysis we used Chi square test. Signifi cance of differences was accepted at p<0,05.

Results. In gravida older than 35 years with preeclampsia there were increased prevalence of preterm

deliveries (Chi=11,134; p=<0,05), SGA (Chi=12,2898; p<0,05) and LBW babies (Chi=24,322; p<0,05).

Nuliparity was associated with occurence of preeclampsia in those gravida (Chi=7,984; p <0,05). Preva-

lence of Cesarean section was increased in study group (Chi=6,5212; p<0,05). There were no differ-

ences in the APGAR score between two groups (Chi=0,499; p=NS).

Conclusions. In gravida older than 35 years preeclampsia has negative impact on the perinatal out-

come.

64


HELLP SYNDROME.

Vesna Sokol.


HEELP syndrome is multiorganic disease characterised by hemolysis, elevated liver enzymes and a low

platelet count.

The syndrome probably represents complication of prexistsing preeclampsia in 10-20% women, al-

though it can be presented as individual clinical entitiy.

HELLP syndrome develops in approximately 1-2 per 1000 pregnancies overall. Most frequently, the

disease is diagnosed between 28- 36 weeks of gestation. In 30% women the disease develops post-

partum.

The most common clinical presentation of the disease is abdominal pain and tenderness in the midepi-

gastrium or in the right upper quadrant. Many patients also complain about nausea and malaise, which

may be mistaken for a nonspecifi c viral illness! Hypertension and proteinuria are present in approxi-

mately 85% of cases, but these symptoms also may be absent in women with otherwise severe HELLP

syndrome. 1-25% of women develops one of the serious complications which includes disseminated

intravascular coagulation (DIC), abruptio placentae, acute renal failure, pulmonary edema, subcapsular

liver hematoma, and retinal detachment.

The diagnosis of HEELP syndrome is based on the following criteria: microangiopathic hemolytic ane-

mia with an elevated LDH or indirect bilirubin and a low serum haptoglobin concentration (≤25 mg/dL),

platelet count ≤100,000 cells/microL, serum LDH ≥600 IU/L or total bilirubin ≥1.2 mg/dL and serum

AST ≥70 IU/L. Additional laboratory testing can be helpful (PT, aPTT etc.) to differentiate HELLP syn-

drome from various diseases with similar clinical presentation.

The cornerstone of therapy is delivery especially if there is a case of pregnancies ≥34 weeks of gesta-

tion, nonreassuring fetal status and a presence of severe maternal disease. For pregnancies less than

34 weeks of gestation in which maternal and fetal status is reassuring the delivery is suggested after a

course of glucocorticoids to accelerate fetal pulmonary maturity. The outcome for mothers with HELLP

syndrome is generally good, but serious complications may occur. The risk of recurrence in future

pregnancies appears to be increased.

From January, 2005. to June 2011. approximately 50 pregnant women with HEELP syndrome were

treated and delivered at the Department of Gynecology and Obstetrics, University Hospital Center, Za-

greb. The clinical course of the disease during pregnancy, labor and postpartum period was reviewed

retrospectively. Clinical data were ascertained after reviewing and collecting all data from the patients’

personal medical documentation.

65


PERINATAL OUTCOME IN WOMEN WITH RECURRENT PREECLAMPSIA VERSUS PREECLAMPSIA IN NULLIPARAS.

Vesna Elveđi Gašparović, Snježana Škrablin, Trpimir Goluža, Petrana Beljan*, Kristina

Kotorac*, Rikić Josipa*.

Department of OB/GYN. Hospital Medical Centre Zagreb. *School of Medicine, University of Zagreb, Croatia.

Preeclampsia has generally been described as a disease of nulliparas. Women with a history of pre-

eclampsia are at risk for recurrence in future pregnancies with a rate of 20-25%.

Aim. The aim of this study was to compare perinatal outcome of recurrent preeclampsia in multiparas

with that of preeclampsia in nulliparas.

Methods. A retrospective 10-year period study from medical records of term pregnancies in women

with preeclampsia who delivered at Petrova University Hospital; 30 women with recurrent preeclamp-

sia were compared with 125 women who developed preeclampsia as nulliparas. Maternal and fetal

variables that were compared included maternal blood pressure, serum biochemistry, rate of preterm

delivery, rate of abruption placentae and neonatal outcome.

Results. Women with recurrent preeclampsia (n=30) compared with nulliparous women (n=125) had a

smaller increase in mean maternal blood pressure (25.3+/-17.1mmHg vs 33.4+/-11.3; t=3.161 p=0.002),

had less proteinuria (++ 29.1% vs 56.3,χ2=6.116 p=0.013) and had born children with a heavier birth-

weight (3034.3g+/-726.3 vs 2478.8 g +/- 867.7; t=-3.242; p=0.002). We found no statistical difference in

the gestational age at delivery, maternal serum biochemistry parameters and rate of abruptio placentae

in compared groups.

Conclusion. Recurrent preeclampsia seems to be less severe and have better perinatal outcome than

preeclampsia in nulliparas.

66


Alpe Adria

Perinatal Congress

Authors’ Index

67


AUTHORS’ INDEX

Anić Jurica Sonja

Anzulović Dunja

Bagosi Z

Bakki Judit

Barth S

Beganović S

Beljan Petrana

Bito Tamas

Blajić Jozo

Ceccarello Matteo

Cecotti Vera Cocco Andrea

Červar Živković Mila

Čolić Ana

de Marini Sergio

Desoye Gernot

Deutsch M

Di Lorenzo Giovanni

Dieber Rotheneder M

Dorfer M

Drušković M

Đelmiš Josip

Elveđi Gasparović Vesna

Falconi Gabriele

Fellner M

Fister Petja

Gasztonyi B

Giacomazzo Barbara

Giuseppina D’Ottavio

Goluža Trpimir

Gramm S

Gverić Ahmetašević Snježana

Gyurkovits Zita

Haasf Josef

Hahn T

Häusler M

Herman Mislav

Horvatiček Marina

Hulina Davor

Huppertz B.

Idris T

Ilijić Krpan Marcela

Ivanišević Marina

Juras Josip

Juretić Emilja

Katona Marta

Kiss Judit

68


Kohnen G

Kolovetsiou

Kotorac Kristina

Kuliš Iva

Lang Uwe

Lanza Paola

Magnet E

Mammana Giovanni

Marton Virag

Mautner E

Mayer Pickel K

Meir Yoram

Memmo Alessia

Meyer-Pickel C

Mole H

Morris Nicholas

Mörtl M

Moser Franz

Müller Wilhelm

Nemeth Gabor

Nenad Veček

Nosan Gregor

Oroszlán T

Orvos Hajnalka

Pal Attila

Panzitthomas T

Paro Panjan Darja

Perin Daniela

Petrović Davor

Petrović Oleg

Podnar P

Premru Sršen Tanja

Prüller F

Radaković Branko

Reich O

Reif Philipp

Reiterer F

Resch Bernhard

Rikić Josipa

Roje Damir

Rukavina Iva

Sajina Stritar B

Schneuber S

Schöll W

Schuster K

Sokol Vesna

69


Starčević Vito

Steblovnik L

Steinbauer E

Stern C

Škrablin Snježana

Tinelli Raffaele

Tomazić M

Tomić Vajdana

Trevisan Ruggero

Trutnovsky G

Tul Mandić N

Tumbarello Cristina

Ulrich D

Vajda Gyorgy

Verdenik I

Višnić Alenka

Vulić Marko

Walcher Wolfgang

Weiss E

Weiss N

Župić Tomislav

70


NOTE

71


NOTE

72


NOTE

73


NOTE

74


NOTE

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