DOI: 10.3897/folmed.68.e154612

Authors: Dibakar Borthakur, Jayashree Raja, Silka Agarwal, Seema Singh

Abstract: Abstract A thyroid nodule (TN) is a structurally discrete lesion within the thyroid gland that can be readily distinguished from the adjoining normal thyroid parenchyma. TNs are more frequently detected these days because of the widespread use of high-resolution imaging techniques for various neck pathologies. A well-circumscribed macroscopic lesion measuring 17 mm ×14 mm ×12 mm was observed in the left lobe of the thyroid gland during routine dissection performed on an embalmed elderly female cadaver for undergraduate teaching. It was firm to the touch and greyish brown in color. In the histological examination, the lesion appeared intensely stained and encapsulated by a thick fibrous capsule having various sizes of thyroid follicles lined by cuboidal to low-columnar epithelium with focal areas of calcification and hemorrhages. There was no sign of local tissue or vascular invasion by the lesion. No nuclear atypia was observed. The lesion was identified as a benign follicular adenoma. This report underscores the significance of recognizing that a thyroid gland that appears to be within normal limits may, in fact, harbor a thyroid nodule of considerable size. The identification of such nodules is of paramount importance, as a significant proportion of benign thyroid lesions found in geriatric women have a high propensity to undergo malignant transformation.

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DOI: 10.3897/folmed.68.e177549

Authors: Burim Neziri, Shqipe Devaja, Samir Durmishi

Abstract: Introduction: Nickel allergy is among the most common contact hypersensitivities worldwide. It affects women predominantly. This study examined whether female nickel-sensitized patients exhibit reversible changes in pulmonary function following a period of nickel avoidance. Aim: To evaluate pulmonary functional parameters (PFPs) in female patients with nickel sensitization and assess changes after nickel avoidance. Materials and methods: Twelve adult women with confirmed nickel hypersensitivity underwent spirometry before and after a 3‑month nickel avoidance program. Measured parameters included forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), and the FEV1/FVC ratio. Paired-sample tests and effect sizes were calculated. Results: All indices changed significantly after avoidance. FVC increased from 2.7±0.7 L to 3.4±0.5 L [t(11)=−5.50, p<0.001, dz=1.59]; FEV1 from 2.4±0.6 L to 2.9±0.4 L [t(11)=−4.68, p=0.001, dz=1.35]; PEF from 3.9±1.3 L/s to 6.1±0.5 L/s [t(11)=−6.81, p<0.001, dz=1.97]; and the FEV1/FVC ratio from 82.9±2.9% to 89.6±7.5% [t(11)=4.39, p=0.001, dz=1.27]. Conclusion: In women with nickel allergy, pulmonary function improves significantly after nickel avoidance. Pulmonary assessment and avoidance counseling should be integrated into the management of female nickel‑sensitized patients with respiratory symptoms.

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DOI: 10.3897/folmed.67.e142724

Authors: Zahraa Muhmmed Jameel Al-Sattam, Zuhair Basheer Kamal

Abstract: Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder that is either X-linked or autosomal recessive and is characterized by recurrent infections. The diagnosis is primarily based on the nitroblue tetrazolium dye reduction test. Here, we present the case of a 28-year-old pregnant woman with CGD who was diagnosed before marriage and who presented with recurrent subcutaneous skin and ocular infections. Following treatment with multiple antibacterial agents, including meropenem, her infections resolved, and she gave birth to a healthy baby girl at term. However, the newborn has now started to exhibit similar symptoms to those experienced by her mother. This case highlights the need for further studies on the potential impact of maternal chemotherapy on CGD.

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DOI: 10.3897/folmed.67.e142694

Authors: Slavyana Galeva, Boris Stoilov, Ekaterina Uchikova

Abstract: Non-invasive prenatal testing (NIPT) has transformed prenatal screening, offering high sensitivity and specificity in the detection of common fetal aneuploidies. However, discordant results—where NIPT findings do not align with those of confirmatory diagnostics—pose challenges for clinical interpretation and patient counseling. This study aims to analyze the contributing factors and clinical implications of discordant NIPT results using two illustrative case studies. Two cases with discordant NIPT findings were examined. Case 1 involved unexplained fetal growth restriction with normal NIPT results, while Case 2 presented a false-positive NIPT result indicating trisomy 7. Both cases underwent invasive testing (amniocentesis) and comprehensive ultrasound evaluation. In Case 1, a chromosomal microdeletion (4p16.3) associated with Wolf-Hirschhorn syndrome was identified despite normal NIPT results. In Case 2, the suspected trisomy 7 was not confirmed by invasive testing, suggesting confined placental mosaicism or technical limitations as potential causes of discordance. Discordant non-invasive prenatal testing (NIPT) results may arise from biological factors, such as confined placental mosaicism or maternal conditions, or from technical constraints. These cases underscore the importance of invasive confirmatory testing and multidisciplinary counseling to ensure an accurate diagnosis and enable informed decision-making in prenatal care.

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DOI: 10.3897/folmed.67.e155013

Authors: Vesselina Koleva-Topova, Sevim Shefket

Abstract: Introduction: Human epididymis protein 4 (HE4) is increasingly utilized in diagnosing pelvic masses and monitoring patients with ovarian or endometrial carcinoma. However, various publications and diagnostic kit manufacturers report a wide range of reference and threshold values, complicating accurate clinical interpretation and reducing the marker’s clinical utility. This study aimed to establish reference values for HE4 in the Bulgarian female population and investigate the impact of physiological factors such as age, menopause, and pregnancy, as well as pathological conditions like impaired renal function, on marker levels. Materials and methods: The study included 338 women: 246 healthy, nonpregnant women aged 20–82 (124 of whom were premenopausal); 52 pregnant women; and 40 women with reduced renal function, as determined by serum creatinine levels. Data were collected on gynecological status, renal and hepatic function, diabetes, and other clinically significant chronic or oncological diseases. Serum HE4 concentrations were measured using an indirect chemiluminescent microparticle immunoassay (CMIA) on the Architect ci8200 system (Abbott Diagnostics). Statistical analyses were performed using SPSS version 25.0, and values were considered statistically significant at p<0.05. Results: The upper reference limit for HE4 in healthy women (95th percentile with 95% confidence interval) was 62.43 (59.02–65.45) pmol/L. For menopausal status, upper reference limits were 53.22 (50.80–60.82) pmol/L for premenopausal women and 65.31 (61.57–68.35) pmol/L for postmenopausal women. In pregnant women, the upper HE4 limit was 50.90 pmol/L, with values by gestational age of 57.73 pmol/L (first trimester) and 46.35 pmol/L (second trimester). None of the women with serum creatinine within the reference range had elevated HE4 levels, whereas all patients with elevated creatinine had HE4 levels above the 95th percentile for their respective age and menopausal status. Conclusions: The established reference limits for HE4 in this study significantly differ from those proposed by Abbott Diagnostics that are used to date. Implementing these limits in clinical practice could enhance the marker’s sensitivity and enable earlier detection of gynecological malignancies. The data confirm that HE4 levels depend on age, particularly after 60 years, and on reduced renal function, necessitating cautious interpretation in these patients. No significant differences in HE4 concentrations were observed between pregnant and non-pregnant women, supporting the use of uniform reference values regardless of pregnancy or gestational stage.

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DOI: 10.3897/folmed.67.e139838

Authors: Krum Vladov, Ekaterina Uchikova, Maria Koleva-Ivanova, Kamen Yamakov, Veselin Belovezhdov, Gita Yamakova-Vladova, Eleonora Hristova-Atanasova

Abstract: The increased frequency of precancerous lesions and malignant diseases of the vulva is a hallmark of the postmenopausal period. However, the development of fibroepithelial polyps, which are benign neoplasms, is also possible. The exact etiology and pathogenesis remain unclear. These mesenchymal neoplasms are mostly diagnosed in women who received hormone replacement therapy or those who are of reproductive age, with pregnancy being a predisposing factor. We present a clinical case in which surgical treatment was the first choice, and histopathological examination confirmed the diagnosis. The authors report a case of a postmenopausal patient not taking hormone replacement therapy with a single, large, benign, pedunculated fibroepithelial polyp of the vulva (more than 5 cm long) that appeared more than 15 years ago. The polyp was successfully excised, with a good prognosis for the patient. This clinical case emphasizes the accurate clinical diagnosis and the importance of histopathological examination. It illustrates delayed help-seeking in the absence of mandatory prophylaxis.

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DOI: 10.3897/folmed.67.e146769

Authors: Ali Mohammed Ali Al-Nuaimi

Abstract: Aim: To investigate the value of the hematological indices to differentiate bacterial vaginosis (BV) from vulvovaginal candidiasis (VVC) and predict treatment response. Materials and methods: This nested case-control study included 390 women divided into three groups: healthy women, women diagnosed with BV, and women diagnosed with VVC. Additionally, two groups (BV and VVC) were treated and followed prospectively until cured. Demographic data, blood indices, and high-sensitivity C-reactive protein (hsCRP) were obtained from the women. Results: hsCRP and neutrophil-lymphocyte ratio (NLR) showed the best diagnostic utility to predict BV with AUC=0.721 and 0.735, respectively. hsCRP showed the best specificity (99.23%), while NLR showed the best sensitivity (82.31%) to differentiate BV. Regarding percentage change after treatment, NLR showed a higher reduction percentage in the BV group (−27.41±8.151%) than VVC (0.158±5.804%). Conclusions: NLR is an efficient diagnostic instrument for distinguishing individuals with bacterial vaginosis from those with vulvovaginal candidiasis. Its diagnostic reliability is comparable to more regularly used markers such as WBC and hsCRP. Both NLR and PLR are good predictors of clinical response to treatment in bacterial vaginosis.

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DOI: 10.3897/folmed.67.e143849

Authors: Vesselina Koleva, Sevim Shefket, Snezhana Stoencheva

Abstract: Introduction: Endometrial carcinoma (EC) is the most common gynecological cancer among women, and in more than 90% of cases, the initial manifestation of the disease is postmenopausal bleeding. Unfortunately, despite early diagnosis and treatment, EC often recurs. Among the many serum tumor markers studied, human epididymis protein 4 (HE4) and cancer antigen 125 (CA125) show the most promise as tools for EC diagnosis, prognosis, and monitoring. Aim: The aim of the current study was to evaluate the clinical usefulness of HE4 and CA125, tested either as single markers or in combination by including them in the Risk of Ovarian Malignancy Algorithms (ROMA) and in Copenhagen index (CPH-I). Material and methods: In this retrospective study, 1262 women (74 with confirmed EC) were included. The patients with EC had significantly higher values for HE4, CA125, ROMA, and CPH-I (p<0.001) than the healthy women and patients with benign diseases. The subgroup analysis based on the histological type of EC revealed that the highest markers and algorithms were recorded in type II EC group. Results: The ROC curve analysis showed that the best diagnostic performance for detecting EC among patients with benign diseases was the ROMA index (AUC=0.869; 95% CI: 0.818-0.920), followed by CPH-I (AUC=0.822; 95% CI: 0.757-0.887), and HE4 (AUC=0.816; 95% CI: 0.750-0.881). Tested alone, CA125 presented unsatisfactory results for this purpose. Both algorithms proved to have a correlation with the disease stage and progression better than the markers alone (HR=1.046 vs. HR=1.018). Conclusion: In summary, the ROMA index, CPH-I, and, to a lesser extent, standalone HE4 testing can supplement imaging methods as reliable tools for diagnosing and distinguishing patients with EC from those with benign conditions. They have potential as prognostic markers for advanced disease and could help gynecological oncologists to develop a therapeutic strategy.

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DOI: 10.3897/folmed.66.e130668

Authors: Darina N. Ruschukova, Teodora D. Momchilova, Marieta S. Vladimirova, Zlatina I. Nikolova, Krikor O. Indjian

Abstract: Introduction: Cervical cancer causes major morbidity and mortality around the world. This makes prophylactic vaccines a significant tool for preventing the disease. As these vaccines become more widely available, they have the potential to drastically lower the cancer’s prevalence and burden in the future. Aim: The aim of this study was to assess the attitudes toward awareness of the human papillomavirus (HPV) vaccination. Materials and methods: A pilot, cross-sectional, medicosocial survey was conducted using a structured, anonymous online questionnaire, including self-assessment questions on awareness and attitudes towards HPV vaccination. Sixty-four adult female parents of female children participated in the study between June and August 2023. The design and conduct of the study was done with the personal involvement of the researchers. SPSS v. 23.0 was used to analyze the primary statistical information. The results obtained were presented graphically using MS Excel 2010. Results: We found significantly good awareness and negative attitude towards vaccination as prevention against HPV. Conclusion: The present study demonstrated that respondents had a relatively good awareness of cervical cancer, the risk factors associated with the disease, and the virus that causes it. There was a correlation between socio-demographic characteristics and awareness of the study population. The respondents had a certain distrust of the vaccine. The dissatisfaction stemmed from the fact that vaccination was not a substitute for routine cervical screening, was not 100% effective, and did not provide protection against any type of papilloma virus or against pre-existing HPV infections. The low vaccination coverage in Bulgaria leads the authors to believe that our country urgently needs new strategies and approaches in the fight against cervical cancer, through continuous training of medical personnel, inclusion of immunization programs in school health care, and improved health education and awareness of HPV vaccination among adolescent girls and their parents.

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DOI: 10.3897/folmed.66.e125587

Authors: Huma Salahuddin, Rehana Rehman, Sadia Rehman, Muhammad Raza Sarfraz, Raheela Rafiq, Fatima Rehman

Abstract: Background: Infertility, which affects 8%–12% of couples worldwide and 21.9% of couples in Pakistan in particular, is a major reproductive health issue. In vitro fertilization (IVF) has emerged as a prevalent therapeutic intervention. Recent studies have identified insulin-like growth factor-I (IGF-I) as a promising biomarker for assessing embryo viability and predicting implantation outcomes in IVF procedures. Objective: To evaluate the relationship between IGF-I levels and IVF outcomes in women with primary and secondary infertility. Materials and methods: This prospective cohort study included 133 infertile women (99 with primary infertility and 34 with secondary infertility) aged 20-45 years. IGF-I levels were measured using an ELISA kit. Participants were grouped based on infertility type and cause of infertility. Statistical analyses included the Mann-Whitney U test, Pearson chi-square test, Kruskal-Wallis test, and Pearson correlation coefficient. Results: Women with secondary infertility had significantly higher IGF-I levels compared to those with primary infertility (279.40±85.89 ng/ml vs. 239.11±74.55 ng/ml, p=0.02). Male factors were the predominant cause of infertility in both groups. Patients with male-factor infertility had the highest IGF-I levels (267.1±77.6 ng/ml). Significant positive correlations were found between IGF-I levels and the number of oocytes fertilized (r=0.398, p<0.01), oocytes retrieved (r=0.326, p<0.01), oocytes at metaphase II (r=0.386, p<0.01), and cleaved embryos (r=0.369, p<0.01). Conclusion: This study demonstrates a positive correlation between IGF-I levels and various IVF outcomes. Higher IGF-I levels were associated with improved oocyte retrieval, fertilization, and embryo development.

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DOI: 10.3897/folmed.66.e120535

Authors: Daniela Taneva, Angelina Kirkova-Bogdanova, Marieta Todorova, Veselina Bukova

Abstract: Introduction: The consequences of osteoporotic fractures are extremely detrimental to the individual as well as to society. Adopting effective preventative measures is a top public health priority. Aim: This paper deals with the development and validation of an osteoporosis knowledge measurement tool. Materials and methods: The study sample included 335 healthy women aged between 25 and 51 years. The osteoporosis knowledge measurement tool is an adapted version of the osteoporosis knowledge assessment tool (OKAT). To determine the validity and reliability of the tool, we examined the psychometric properties. Nonparametric methods were used for the statistical analysis. Results: Flesch reading ease index was 55.14. The Cronbach’s α value was 0.884. The corrected item-total correlations varied between 0.340 and 0.611. The items’ mean difficulty was 0.46. The mean discrimination index was 0.61. The mean score of the sample was M=12.64±5.164, a little bit higher than 50% of the success rate. Conclusion: The tool can be used in different settings to assess educational needs and plan interventions. The results indicate a need for educational and preventive initiatives.

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DOI: 10.3897/folmed.66.e119961

Authors: Edon Behluli, Enis Veseli, Argjira Veseli

Abstract: Aim: This study aimed to analyze the oral health conditions of pregnant women. The analysis involves evaluating two key indices: the decayed, missing, and filled teeth (DMFT) index and the basic erosive wear examination (BEWE) index. Furthermore, this study investigated potential correlations between calcium (Ca) and phosphate (P) levels within specific time intervals and the aforementioned oral health indices. Materials and methods: This study included 66 women. The examination consisted of assessing the condition of the teeth by using the DMFT index. Additionally, the erosive decay of the teeth was evaluated according to the BEWE index. Salivary concentrations of Ca and P were determined using a colorimetric method. These measurements were performed during the first (T1) and third (T3) trimesters of pregnancy. Results: The study results showed that the DMFT index value in T3 was significantly higher compared to that in T1. However, there were no significant differences in BEWE index values between the two time intervals. Furthermore, notable differences were observed in the levels of Ca and P between T1 and T3 (Z=4.87, p=0.000 and Z=2.95, p=0.003, respectively). Nevertheless, the analysis of the relationship between DMFT/BEWE indices and Ca and P levels found no significant correlation. Conclusions: The results suggest that the third trimester poses a greater oral health burden. Additionally, there were notable fluctuations in the Ca and P levels during pregnancy. These findings shed light on the correlation between pregnancy phases and oral health indicators, emphasizing the significance of the salivary composition.

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DOI: 10.3897/folmed.66.e116865

Authors: Dimitrios Bairaktaris, Stefania Tsoplaktsoglou, Efthymia Souka, Konstantinos Kalmantis, Christos Iavazzo

Abstract: Paraovarian tumors of borderline malignancy (PTBM) are exceedingly rare, with only slightly over 60 cases reported worldwide. This report presents the case of a 22-year-old nulliparous patient who incidentally discovered a left paraovarian mass during a routine abdominal ultrasound. Subsequent MRI revealed a 2.5×2.1 cm cystic lesion located in close proximity to, but outside of, the left ovary, with no other pathological findings. A laparoscopic cystectomy was performed with meticulous care to prevent tumor spillage, and the patient experienced an uneventful recovery. Histopathological examination unveiled irregularly shaped tissue measuring 2.2×1.2×1 cm, characterized by fibrous tissue/wall with spindle cell stroma and an epithelium displaying features consistent with a serous borderline tumor. Our multidisciplinary team recommended diligent follow-up. This case contributes to the existing literature on PTBM and highlights the imperative for additional cases to enhance our comprehension of the optimal management of these exceedingly rare tumors.

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DOI: 10.3897/folmed.65.e100064

Authors: Georgi D. Prandzhev, Tihomir P. Totev, Svetlana A. Mateva, George Mathew, Grigor A. Gortchev

Abstract: Uterine tumor resembling ovarian sex-cord tumor is a rare group of uterine neoplasms with unknown histogenesis and differentiation towards ovarian sex-cord elements. They are benign in nature with low malignancy potential. Diagnosis is based on immunohistochemistry and morphological features, and the distinction from other more malignant differentials is paramount to correctly individualizing treatment. A 47-year-old patient was admitted to the hospital complaining of abdominal pain and abnormal uterine bleeding. Subsequent detection of multiple uterine fibroids by ultrasound study and CT scans lead to a robot-assisted total hysterectomy. Histological studies revealed that one of the fibroids in the myometrium had a morphology resembling an ovarian sex-cord tumor with low Ki-67 proliferative activity. After 12 months of follow-up, no additional treatment was required, and no signs of recurrence or progression were observed. Uterine tumor resembling ovarian sex-cord tumor is a rare gynecological entity with no established treatment protocol. Differentiation between benign and malignant behavior is based on structural features and immunohistochemical expression assessment. This highlights the importance of immunohistochemical staining and morphological analysis to determine the degree of surgical radicality. Minimally invasive approach is feasible and safe, but more experience is needed for further conclusions.

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DOI: 10.3897/folmed.65.e90054

Authors: Vasiliki Papadatou, Stylianos Tologkos, Theodora Deftereou, Triantafyllos Alexiadis, Olga Pagonopoulou, Christina-Angelika Alexiadi, Panagiota Bakatselou, Sadik Tzem Chousein Oglou, Grigorios Tripsianis, Achilleas Mitrakas, Maria Lambropoulou

Abstract: Introduction: Parvoviruses are DNA viruses of small size. There have been a number of reports indicating the possible effects of B19 infections during pregnancy. These effects include spontaneous abortions, stillbirth, fetal damage, and quite often, fetal anemia with hydrops fetalis. Aim: The aim of this study was the correlation of Epstein-Barr virus (EBV) and parvovirus-B19 infections with inflammation levels in placental tissue coming from spontaneous abortions and elective terminations cases. We also investigated whether viral presence could cause spontaneous abortions by associating the expression levels of inflammatory markers with adverse pregnancy outcomes. Materials and methods: One hundred ninety-four placental samples were used, 152 included in the study group coming from spontaneous abortions while 42 controls were used from cases of elective terminations. Hematoxylin and eosin (H&E) staining was performed to investigate morphological changes in the tissues, and then indirect immunohistochemistry to evaluate the expression of TNF-α, IL-6, IL-1α, B19, and EBV. Statistical analysis was performed using SPSS v. 19.0 (IBM). Results: Higher inflammation levels were observed with statistical significance in the spontaneous abortions group (p<0.001) and they were correlated with statistical significance with B19 or EBV presence (p<0.001). Viral presence was only found in the spontaneous abortions group. Both simple and multiple logistic regression confirmed that viral presence was an independent prognostic factor for high expression of all inflammatory biomarkers with statistical significance (p<0.001). Conclusions: Our results clearly indicate a specific pattern. Viral presence can deregulate inflammatory processes in the maternal-fetal environment and thus work as a trigger for spontaneous abortions.

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DOI: 10.3897/folmed.65.e99159

Authors: Vasilii S. Chulkov, Ekaterina Nikolenko, Vladislav Chulkov, Anastasia Podzolko

Abstract: Hypertensive disorders of pregnancy are a worldwide health problem for women. They cause complications in up to 10% of pregnancies and are associated with increased maternal and neonatal morbidity and mortality. Traditional blood pressure measurement in clinical practice is the most commonly used procedure for diagnosing and monitoring hypertension treatment, but it is prone to significant inaccuracies caused, on the one hand, by the inherent variability of blood pressure and, on the other, by errors arising from measurement technique and conditions. Some studies have demonstrated a better estimate of the prognosis for the development of cardiovascular diseases using ambulatory blood pressure monitoring. We can detect white-coat hypertension using this method, which helps to avoid overdiagnosis and overtreatment in many cases, and we can also detect masked hypertension, which helps to avoid underdiagnosis and a lack of prescribed treatment if needed. White-coat hypertension is not a benign condition – it has been shown to be associated with higher risks of developing preeclampsia, preterm birth, and small-for-gestational-age babies. In this regard, it is extremely important for clinicians to be aware of the risk factors and outcomes associated with this condition. Pregnant women should be medically monitored both during pregnancy and after delivery to detect target organ damage, cardiovascular risk factors, or a metabolic syndrome.

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DOI: 10.3897/folmed.65.e83315

Authors: Daniela Taneva, Angelina Kirkova-Bogdanova, Marieta Vladimirova, Radoslava Katsarska, Maria Vakrilova-Becheva

Abstract: Introduction: Population reproduction and family planning are highly dependent on sexual culture and sexual behavior. In this study, we seek to determine whether, over a ten-year period from 2009 to 2019, there have been any changes in the sexual culture of nursing students in relation to the knowledge of risk factors for unintended pregnancies and subsequent abortions. Materials and methods: A group anonymous survey was used to gather primary data from 219 nursing students from the Medical College at the Medical University of Plovdiv in 2009 and 210 nursing students from the Faculty of Public Health at the same institution in 2019. The studies in both cohorts were cross-sectional. Results and discussion: We found that students’ perceptions of sexual culture did not change significantly in the study period. There were some changes in the students’ attitudes toward voluntary abortion in the ten years between 2009 and 2019. Age and marital status were found to be essential factors in determining whether an unplanned pregnancy would be maintained or aborted. Future medical professionals are aware of how having an abortion affects a woman’s health and ability to reproduce. Conclusions: In promoting sexual and reproductive health, medical professionals play a crucial role. It is, therefore, essential that a course on sexual health be added to the curriculum of medical universities training healthcare professionals.

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DOI: 10.3897/folmed.65.e86087

Authors: Boris Stoilov, Polina Zaharieva-Dinkova, Lili Stoilova, Ekaterina Uchikova, Emiliya Karaslavova

Abstract: Introduction: One of the major obstetrical complications, affecting 2%–8% of all pregnancies, is preeclampsia. To predict the onset of preeclampsia, several methods have recently been put forth. The Fetal Medicine Foundation has developed combined screening that can identify the vast majority of women who will develop preeclampsia using a combination of maternal factors, obstetrical history, biochemical, and biophysical factors. Aim: The objective of the present study was to identify and analyze which classical risk factors may be independent predictors of preeclampsia, and assess their impact on this complication. In order to assess the high risk of preeclampsia, we also suggest further predictors that may optimize the risk constellation. Materials and methods: The study included 1511 pregnant women who were examined during their routine checkups in a two-phase retrospective study that took place from January 30, 2018, to August 31, 2020, in the Outpatient Department of the University Hospital in Plovdiv. All primary data were obtained from their archived medical records. Information about the maternal factors, the patients’ medical and obstetric histories, and status was obtained during the first phase of the study (11th gestation week + 0 days – 13th gestation week + 6 days). The second phase was conducted as a telephone interview (up to six months after the birth of the child): we collected data on the mode of birth, weight of the newborn, PE occurrence, at which gestation week the PE onset occurred, presence of gestational hypertension (GH) and diabetes, intrauterine growth retardation (IUGR), whether patients took aspirin and in what dosage, other complications, etc. The patients were divided into two groups: a high-risk group (with a risk for PE higher than 1:150), and a low-risk group, with or without onset of IUGR, GH, diabetes, etc. Results: The mean age of the analyzed 1511 pregnant women was 29.91±5.32 years (range 18 – 46 years). Of these, 38 (2.9%) women developed preeclampsia, and 5.9% had gestational hypertension. The classification of participants by risk of developing preeclampsia showed that 591 (39.1%) of the examined patients were reported as high-risk. All patients at risk higher than 1:150 were classified as high-risk, and it was recommended that they should take aspirin 150 mg every night from 12th to 36th week of gestation. 80.6% of the high-risk group took the medication regularly. Comparing the beta coefficients for the parameters we studied (beta coefficient indicates the predictors’ impact on PE), we established that the risk factors that are the most significant and apparently independent in predicting preeclampsia were (in ascending order): 1. Weight of newborn, β=0.157; 2. Mean arterial blood pressure (MAP), β=0.150; 3. IUGR, β=0.120; 4. Pregnancy associated plasma protein-A (PAPP-A), β=0.112; 5. Cervix length, β=0.095 Conclusions: In the analysis of the four multiple regression models, adequately describing the role (and independence) of the PE predictors – common to all pregnant women; in cases of early midterm and term PE: placental growth factor (PlGF), PAPP-A, MAP, mean Ut PI, cervical length, newborn weight, and IUGR. As common for all cases with PE, and depending on whether the PE onset was ≤32, ≤4, or ≤36 week of gestation, the following conclusions can be made: independent predictors of PE in all studied pregnant women were (indicators are ranked according to their degree of impact on the occurrence of PE): 1. MAP; 2. Intrauterine growth retardation (newborn weight is an indirect indicator of probable IUGR); 3. Pregnancy-associated protein-A; 4. Cervix length (with the corresponding standardized coefficients being β=0.150; β=0.120; β=0.112; β=0.095, respectively).

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DOI: 10.3897/folmed.65.e89198

Authors: Eirini Giovannopoulou, Maria-Valeria Karakasi, Maria Kouroupi, Alexandra Giatromanolaki, Panagiotis Tsikouras, Pavlos Pavlidis

Abstract: Ovarian tissue autotransplantation is an innovative fertility preservation technique that has provoked ongoing investigations. The purpose of the present study was to assess the safety and reproductive performance of ovarian tissue autotransplantation. This review is conducted according to PRISMA guidelines. Seven studies met the inclusion criteria. A total of 3427 patients underwent ovarian tissue cryopreservation and 205 received an autotransplantation. Tissue retrieval was mainly performed by laparoscopy and only one major complication occurred. Transplantations were predominantly performed by open procedures and data on safety were insufficient. A total of 295 autotransplantations were analyzed, resulting in 104 pregnancies. Sixty-five pregnancies led to live births, while nine were ongoing at that time. A pregnancy rate (PR) of 50.7% and a live-birth rate (LBR) of 32.7% were observed. Natural conception accounted for 46.3% of live births. No birth deficits were recorded. Ovarian tissue autotransplantation seems to be a safe procedure with acceptable pregnancy rates.

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DOI: 10.3897/folmed.64.e70074

Authors: Asparuh G. Nikolov, Nikola K. Popovski, Svetla Blazheva

Abstract: Introduction: Podocalyxin (PCX) is an indicator of glomerular injury. Aside from the kidney, it is expressed in the endothelial cells of various organs. Echographic examinations are useful in assessing the alterations in cardiovascular structure and function during pregnancy. Aim: The aim of the present study was to evaluate PCX concentrations in preeclampsia (PE) and to investigate the existence of association between PCX levels and maternal echocardiographic and Doppler ultrasound parameters. Materials and methods: Fifty-five women with PE were examined. The mean age of patients was 24.9±6 years; and the mean age of the control group of 35 women with normal pregnancies was 24.7±5.4 years. ELISA was used to determine concentrations of PCX. Echocardiographic assessment of all subjects was performed. In addition, umbilical (UmA) and uterine (UtA) artery pulsatility indices (PI) were evaluated. Results: The levels of serum PCX in PE women were statistically significantly higher than those in women with normal pregnancy: 2.66±0.67 vs. 2.40±0.33 ng/ml (p=0.03). Cut-off value at 3 ng/ml was obtained for podocalyxin in order to discriminate between PE and healthy pregnancy. Logistic regression model was statistically significant: OR=3.226, (95% CI 1.084–9.599); (p=0.019). PCX correlated with systolic blood pressure (r=0.30; p=0.004), diastolic blood pressure (r=0.35; p=0.0007), UtA PI (r=0.30; p=0.004), UmA PI (r=0.21; p=0.047), IVS (r=0.32; p=0.002), and LVPWD (r=0.28; p=0.007). Conclusions: Healthy pregnant women with PCX levels above the cut-off value of 3 ng/ml are at a higher risk for developing preeclampsia. Elevated PCX levels indicate three times higher probability for PE development than women with values below the cut-off value. PCX might be a promising marker for diagnosis and prognosis of PE.

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DOI: 10.3897/folmed.64.e67757

Authors: Marieta Vladimirova, Diruhi Amudzhiyan, Teodora Momchilova, Maria Vakrilova Becheva

Abstract: Introduction: The share of unwanted pregnancies and voluntary abortions among women from Central and Eastern Europe is still quite high, and Bulgaria is no exception to this statistic. This might be accounted for by the low frequency of use of contraceptives or their improper use. Our country is home to a variety of ethnic groups, with Roma being one of the most numerous, ranking third in population behind Bulgarians and Turks. This determines the influence of this ethnic group on the demographic indicators of the country. Aim: To study the knowledge of contraceptive use and the frequency of use of contraceptive methods and means among Roma women from the Plovdiv region and the factors influencing it. Materials and methods: This cross-sectional survey was conducted among 70 Roma women via structured, anonymous interviews in 2019. Statistical data analysis was performed using non-parametric methods, descriptive and correlation analyses. Results: The main method of preventing unwanted pregnancies for the Roma is the interrupted intercourse. The husband and his mother influence the decision to use contraception. Higher education and financial security have a positive effect on the frequency of contraceptive use. Conclusions: Reproductive behaviour among Roma is largely determined by their ethnic traditions. Characteristic features were observed, such as early marriages, early sexual intercourse, short pro- and intergenetic interval. Roma women have little knowledge of the various methods and means of preventing unwanted pregnancies. The frequency of contraceptive use is very low.

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DOI: 10.3897/folmed.64.e65939

Authors: Corina Iliadi-Tulbure, Maria Cemortan, Cristina Bubulici, Mihaela Botnari-Gutu, Olga Cernetchi

Abstract: Intrahepatic cholestasis of pregnancy is pregnancy-specific liver disorder, characterized by pruritus as the main clinical symptom, and fasting liver function tests. The term thrombophilia is used to describe a group of conditions characterized by blood coagulation disorder with increased risk of blood clot formation, which may be congenital or acquired. In general, population the incidence of thrombophilia and intrahepatic cholestasis of pregnancy varies widely, depending on the type of disorder (in case of congenital thrombophilia) and geographical distribution (in case of intrahepatic cholestasis of pregnancy). A high incidence of pregnancy complications makes both congenital thrombophilia and intrahepatic cholestasis of pregnancy very important in clinical practice. At the same time, association between these two disorders is extremely complicated in management, due to perinatal risks. The key-point for the management is cooperation among obstetricians, hematologists, and hepatologists, being crucial for better outcomes.

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DOI: 10.3897/folmed.64.e64741

Authors: Dolina G. Gencheva, Fedya P. Nikolov, Ekaterina H. Uchikova, Krasimira A. Hristova, Rosen D. Mihaylov, Blagovesta G. Pencheva

Abstract: Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a “stress test” for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases.

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DOI: 10.3897/folmed.64.e60937

Authors: Victoria Psomiadou, Christos Iavazzo, Eirini Geramani, Alexandros Fotiou, Loukas Karelis, Christos Valavanis, Sofia Lekka, Kalliopi Kokkali, George Vorgias

Abstract: Uterine angiolipoleiomyomas are rare, benign mixed mesenchymal lesions. A manifestation in the gynecological region is quite uncommon, with few cases described in the literature so far. We present an interesting case of a 59-year-old woman diagnosed with uterine angiolipoleiomyoma, and the results of the conducted systematic review of the literature. The patient presented with a pelvic mass masquerading as a leiomyoma on the ultrasound and postmenopausal vaginal bleeding. At laparotomy, a large uterus was noticed and the histopathology set the diagnosis of angiolipoleiomyoma. Immunohistochemistry revealed negativity for Melan-A and HMB-45 melanoma-specific antibodies and positivity for Van Gieson and orcein histochemical stains. We systematically reviewed the literature. The eligible articles were those written in English, excluding animal studies and studies reporting angiolipoleiomyomas in other regions beside the uterus. The present case is one of the 10 cases of uterine angiolipoleiomyoma reported in the literature. In 8 out of 11 (72.7%) cases, uterine angiolipoleiomyomas arose from the corpus of the uterus, while in 2 (18.1%) cases they were located at the cervix, and in one case (9%) angiolipoleiomyoma was located in the broad ligament. Concerning symptoms, four of the patients (36.4%) presented with abdominal and pelvic pain, two (18.1%) with postmenopausal vaginal bleeding, one with menometrorrhagia (9%), and one with uterine prolapse and cystocele (9%). Immunohistochemical staining of uterine angiolipoleiomyomas was positive for SMA in 4 patients (36.4%), positive for desmin in 3 cases (27.3%), positive for anti-S-100 protein antibody in 2 patients (18.1%), while in one case (9%) immunopositivity was observed for CD31. Only our case (9%) was also tested for CD34, Van Gieson and orcein, the first of these being negative and the other two positive (at the blood vessels in a specialized pattern). Three of the patients (27.3%) were also tested for HMB-45 and all three were immunonegative. In order to establish the diagnosis of uterine angiolipoleiomyomas, ultrasonography and additional MRI may help the preoperative prediction of a benign mass. Immunohistochemistry will show strong positivity of alpha-smooth muscle actin and desmin. Complete abdominal hysterectomy is the preferable treatment.

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DOI: 10.3897/folmed.64.e62153

Authors: Elitsa H. Gyokova, Yoana G. Ivanova-Yoncheva, Yordan D. Popov, Ahamed Akkeel Anzaar, Grishma Pradip, Sai Bhamidipati, Henritta Owusu, Krishmila Yogeswaran

Abstract: Introduction: A staggering 30% of deaths in neonates are caused by preterm births. The most common cause of perinatal morbidity and mortality around the world is due to preterm births, also referred to as premature. Hence, the ability to predict preterm births would result in significantly reduced fatalities. The likelihood of predicting a premature birth can be measured by the cervical length; however, there are other diagnostic procedures which utilize the contents of the cervico-vaginal fluid (CVF) for a more precise diagnosis. The latter also aids in detecting other pregnancy related anomalies. The phosphorylated insulin-like growth factor binding protein-1 (pIGFBP-1) is an example of a clinical biomarker which is frequently tested as it proves to be an indicator to predict preterm labour. Aim: Thus, in this study, our aim was to evaluate the accuracy of pIGFBP-1 as a marker of preterm labour when coupled with cervical biometrics. Materials and methods: A cross-sectional study of 32 pregnant women was conducted. The patients were split into 2 groups in which Group A consisted of those at risk of preterm labour and Group B – of women with normal and uncomplicated pregnancies. All participants were tested for pIGFBP-1 along with gathering data of transvaginal measurements of their cervical length. Results: We found in all participants in the study a moderate association between the expression of pIGFBP-1 in the CVF and the onset of preterm birth. Eight patients showed positive results amongst the symptomatic patients and as predicted, within 14 days, 6 of those patients did go into preterm labour. Conclusion: Appropriate scanning for pregnant women can be of excellent value as it has the potential to reduce the number of premature babies being born; this would also mean that the health complications associated with premature births can be prevented.

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DOI: 10.3897/folmed.64.e61406

Authors: Androniki Stavridou, Despoina Michailidou, Eleni Panagouli, Theodoros N. Sergentanis, Efthalia Tzila, Theodora Psaltopoulou, Maria Tsolia, Nikolaos Vlahos, Artemis Tsitsika

Abstract: Fear of COVID-19, especially in vulnerable groups such as pregnant women, created excessive concern leading to unexpected psycho-emotional consequences and a need to summarize the most recent knowledge about this topic. Therefore, we conducted a narrative review of the relevant literature, synthesizing data from available databases. According to the findings of this review, pregnant women during COVID-19 pandemic were more anxious and depressed mainly due to the fear of contacting the virus, the restrictive measures, and concerns about the health of their unborn children. The elevated stress levels in pregnant women due to the pandemic could represent risk factors for physical health complications. Thus, strategies including relaxation, mindfulness, acceptance, and positive attitude to COVID-19 should be promoted for pregnant women.

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DOI: 10.3897/folmed.63.e58002

Authors: Kalliopi Kokkali, Christos Iavazzo, Efthimia Souka, Sofia Lekka, Alexandros Fotiou, Eirini Geramani, Victoria Psomiadou, George Vorgias

Abstract: Crohn’s disease is a multi-systemic chronic inflammatory disease that can affect various organs besides the gastrointestinal tract such as joints, uvea, and the skin. Vulvar Crohn’s disease is a rare entity occurring with vulvar lesions that show typical Crohn’s disease granulomatous inflammation but are not contiguous with the gastrointestinal involvement. Vulvar Crohn’s disease can be easily confused with other granulomatous diseases and awareness that such involvement may precede gastrointestinal symptoms must be raised. Few cases of vulvar Crohn’s disease have been reported in the literature to date. Here, we report a case of a 43-year-old woman with a 6-month history of a vulvar lesion; the patient was diagnosed with Crohn’s disease of the large bowel just over a year ago.

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DOI: 10.3897/folmed.63.e60055

Authors: Irena Kostovska, Katerina Tosheska Trajkovska, Ognen Kostovski, Danica Labudovic

Abstract: Introduction: Pre-eclampsia (PE) is characterized by new-onset hypertension and proteinuria. Damage of podocyte cells has been reported in pre-eclamptic women, thus podocyte specific proteins such as nephrin and podocalyxin could be useful biomarkers in PE.Aim: To investigate the role of urinary nephrin (u-nephrin) and urinary podocalyxin (u-PDX) levels in predicting PE in women with a high-risk pregnancy.Materials and methods: We included 101 pregnant women in this study and allocated them into three groups: group 1 included pregnant women at high risk of developing PE (n=41), group 2 - pregnant women with PE (n=30), and group 3 was the controls including healthy pregnant women (n=30). The inclusion criteria for women with PE were de novo hypertension >140/90 mm Hg, proteinuria >300 mg/24 hours, and presence of edema after 20 weeks of gestation, while the exclusion criteria were a history of renal diseases and pregnant women younger than 18. Inclusion criteria for the group of women with a high-risk pregnancy was gestational week >15, a history of PE in a previous pregnancy, pre-existing diabetes type 1 or 2, pre-existing hypertension, multiple gestations, prior placental abruption, obesity women, nulliparity, maternal age >35 years, and a family history of PE. The study was conducted from March 2016 to May 2017 in the Medical Faculty at the Institute of Medical and Experimental Biochemistry in Skopje. Urine samples were used to measure the nephrin and podocalyxin levels using immunoenzyme assay, creatinine and microalbumin. Blood samples were collected for biochemical analyses.Results: U-nephrin levels were elevated in 96.7% of women with PE, and 73% of women with a high-risk pregnancy. U-PDX levels were elevated in 63% of the women with PE and 100% of the women with a high-risk pregnancy. U-nephrin and u-PDX levels were significantly increased in women with a high-risk pregnancy and women with PE compared with a control group (p<0.001). A significant difference was found between the subgroups of pregnant women classified according to gestational age in their u-nephrin and u-PDX levels. There was a significant positive correlation between the levels of both markers and glomerular filtration rate, and significant negative correlation between the levels of both markers and gestational age. ROC analysis revealed that the cut-off value of 304.6 ng/ml of u-nephrin had a sensitivity (Se) of 96.7%, specificity (Sp) of 96.7% (for both Se and Sp 95% confidence interval (CI) 82.8-99.9), while the cut-off value of 59.5 ng/ml of u-PDX had a sensitivity of 100% and Sp of 93.3% (Se - 95% CI 88.4-100, Sp - 95% CI 77.9-99.2), in distinguishing women with PE and healthy pregnancies. Both markers showed excellent clinical utility (CUI≥0.81), for u-nephrin (CUI+ and CUI− is 0.934), for u-PDX (CUI+ is 0.938; CUI− is 0.933).Conclusions: U-nephrin and U-PDX levels could be useful as predictors of PE in women with a high-risk pregnancy.

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DOI: 10.3897/folmed.63.e60249

Authors: Asparuh G. Nikolov, Nikola K. Popovski, Alexander B. Blazhev, Svetla Blazheva

Abstract: Introduction: Collagen type I is a major structural component of human uterus. Recent studies have found that collagen type I turnover is altered in preeclampsia and imbalance occurs between collagen synthesis and degradation processes. This acts as a stimulus for abnormal changes in the concentrations of collagen type I derived products in circulating blood.Aim: Having in mind the pathological collagen type I turnover in preeclampisa, the aim of the present study was to determine the levels of N-terminal propeptide of collagen type I (PINP), C-terminal propeptide of collagen type I (PICP): both markers of collagen type I synthesis and levels of matrix metalloproteinase-1 (MMP-1): marker of collagen type I degradation in sera of women with early-onset preeclampsia.Materials and methods: Thirty-two patients with early-onset preeclampsia were examined. The mean age of the patients was 28.8±5.5 years; and the mean age of 22 age-matched healthy pregnant women was 28.5±6.0 years. The enzyme-linked immunosorbent assay (ELISA) was used for measuring serum levels of PINP, PICP and MMP-1.Results: There were no statistically significant differences between levels of PINP, PICP and MMP-1 in the sera of women with preeclampsia and healthy pregnancies: 16.991 (15.41÷21.143) vs. 17.189 (15.805÷20.747) µg/L (KW=0.02; p>0.05), 10.929 (8.7÷13.937) vs. 11.474 (7.369÷11.932) µg/L (KW=0.026; p>0.05), and 2.097 (1.384÷2.923) vs. 2.589 (1.41÷4.533) µg/L (KW=0.238; p>0.05), respectively. There were statistically significantly higher number of patients from the preeclampsia group than healthy pregnant women with BMI≥25 (23/32 vs. 4/22) and abnormal UAD (18/32 vs. 2/22) (p<0.05).Conclusions: Our results did not show significant differences between serum levels of PINP, PICP and MMP-1 (markers of collagen type I turnover) in women with early-onset preeclampsia and healthy pregnancy. Further studies with more specific methods and larger sample size are required to assess changes in the serum levels of PINP, PICP and MMP-1 in early-onset preeclampsia.

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DOI: 10.3897/folmed.63.e55388

Authors: Dimitrios Tsapralis, Anastasia Prodromidou, Georgios Vasiliadis, Chrysovalantis Vergadis, Nikolaos Machairas, Athanasios Syllaios, Evangelos Misiakos, Dimitrios Schizas

Abstract: Mature cystic teratomas (MCT) of the ovary or dermoid cysts are commonly encountered benign ovarian lesions accounting for approximately 70% of benign tumors and originating from germ cells. A rare case of peritonitis in a 17-year-old female patient caused by traumatic rupture of an MCT of the right ovary is herein presented. A meticulous search of the literature has also been performed. Due to deterioration of patient’s clinical condition, she was urgently led to surgery and intraoperative investigation of the peritoneal cavity revealed an inflamed ruptured ovarian cyst along with extensive peritoneal adhesions and purulent peritoneal fluid. A cyst resec-tion was performed with preservation of the ovary followed by adhesiolysis and meticulous abdominal washing and the patient had an uneventful recovery. Despite its rarity, traumatic rupture of ovarian cyst should be considered at evaluation of trauma patients with special attention to cases with a discovered or known presence of ovarian cyst.

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DOI: 10.3897/folmed.63.e54171

Authors: Antonios Koutras, Zacharias Fasoulakis, Arzou Halil, Emmanuel N. Kontomanolis

Abstract: Echogenic intracardiac focus (EIF) constitutes a finding in the ultrasound study that indicates an area which is echogenically bright in the fetal heart and is as bright as the bone that moves synchronically to the atrioventricular valves. Microcalcifications of the papillary muscles or chordae tendinae are being represented by this echogenicity and are mostly present in the left ventricle (90% of cases). EIF appears usually at the ultrasound that is realized in the mid-trimester in a percentage that reaches 3.5% in euploid fetuses and 15% to 30% in fetuses with trisomy 21. In the current paper, the rare and curious case of a 21-year-old primigravida woman is described, who presented for ultrasound scan at the 12th week of gestation. The scan revealed the presence of EIF, which is very rare, as it is well-known that it usually appears in the second trimester of pregnancy. Counseling and debriefing for dismissing parents’ anxiety is necessary as well as further examinations, because EIF has low sensitivity. This specific case report could constitute a beginning in the research of whether investigating EIF in the first trimester of pregnancy is possible and which are the benefits of its detection for the mother, the fetus and the whole family, in clinical practice.

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DOI: 10.3897/folmed.62.e51551

Authors: Spasimir T. Shopov

Abstract: A collision tumor represents a coexistence of two adjacent but histologically distinct tumors without histologic admixture in an organ. Serous tumors of the ovary are the most common forms of epithelial tumors, and cavernous hemangiomas are rare in the ovary. Howev-er, a collision between them is an extremely rare pathology. Here the author presents a report of a 74-year-old woman whose ultrasound examines establishes rounded left ovary formation with hypo- and hyperdense sections. Paraclinical: CA125 within normal range. Serum levels free testosterone 3.79 nmol/l (normal 0.49-2.64 nmol/l for women). The histology showed benign serous cystadenoma and vascular lesions composed of capillary and cavernous vessels amongst luteinized stromal cells. The luteinized cells were positive for inhibin A. The endothelial cells were negative for estrogen and progesterone receptor. A search was conducted in the Medline database via PubMed using the terms: ‘hemangioma’, ‘ovary’, ‘collision’, ‘serous cystadenoma’, no more than 70 articles for ovarian hemangiomas appeared, and no articles for a collision between serous cystadenoma and mixed hemangioma with stromal luteinization in the ovary. From the reference, this is the first reported case of collision between serous cystadenoma and mixed cavernous-capillary hemangioma with stromal luteinization in the ovary. This rare case of collision between tumors in the ovary sheds light on possible tumor pathology in the woman’s reproductive system, which must be considered by gynaecologists and pathologists.

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DOI: 10.3897/folmed.62.e50166

Authors: Vesselina Yanachkova, Radiana Staynova

Abstract: Insulin-induced lipoatrophy is a rare skin complication in patients with diabetes mellitus. It is characterized primarily by localized subcutaneous atrophy of the fatty tissue at the site of frequent insulin injection. We report a clinical case of a 38-year-old woman with lipoatrophy, developed during treatment with insulin analogues. Lipoatrophic zone formation began 3 months after the treatment was initiated. A lipoatrophic defect developed on the thighs and the upper outer arms, resulting from repeated insulin injections at the same site. Regarding lipoatrophic areas, treatment with topical administration of corticosteroids was attempted but without a significant clinical effect. The best prevention from lipoatrophy development is education of patients regarding rotation of insulin injection sites and more frequent needle change.

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DOI: 10.3897/folmed.62.e49276

Authors: Samantha Mc Kenzie Stancu, Manuela Cristina Russu

Abstract: Introduction: Appropriate intrapartum conduct in a twin delivery remains a challenging aspect of obstetric practice. The objective of this study was to compare neonatal and maternal outcomes in twin pregnancies according to mode of delivery. Materials and methods: This is a single centre retrospective cohort study of all consecutive spontaneously-conceived twin deliver-ies (≥ 24 weeks, estimated fetal weight ≥ 500 grams) over a nine-year period between 01/01/2007 - 31/12/2016 at a tertiary-level centre. Neonatal outcomes included survival, APGAR score, prematurity-associated pathology (PAP), admission to the neonatal intensive care unit (NICU) and length of stay (LOS). Maternal outcomes included postpartum complications and LOS. Statistical analysis comprised Chi-square test with subsequent p-value and odds-ratio with 95% confidence interval. Statistical significance was set at p<0.05.Results: A total of 173 consecutive women with spontaneously-conceived twin deliveries were enrolled in this study, 129 (74.6%) women delivered by caesarean section (CS). The success rate of vaginal delivery (VD) was 93.6% (44/47). A strong statistical correlation was identified between CS and NICU admission; 53.2% vs. 1.5% (p=0.0001). Neonatal LOS in the NICU was significantly longer in the CS group. Prematurity-associated pathology (PAP) was noted in 75 pairs of twins (75/173); 61 pairs were delivered by CS, bearing strong statistical significance (p<0.0001). Postpartum complications occurred in 14.7% of CS compared to 13.6% of VDs. Conclusion: Neonates delivered by CS had a higher rate of PAP, NICU admission, lower birth weight and longer LOS. This study showed that VD is safe, especially when the first twin is in cephalic presentation

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DOI: 10.3897/folmed.62.e47920

Authors: Christos Iavazzo, George Iatrakis, Paraskevi-Evangelia Iavazzo, Konstadia Bakalianou, Ioannis D. Gkegkes

Abstract: The change in life expectancy affects the clinical presentation and the prognosis of elderly patients with gynecological cancer. The in-crease of life expectancy and increased numbers of elderly patients, the healthcare systems have to deal more frequently with patients who are not simply older adults but have also severe comorbidities and physiological, psychological, functional, and social needs that require individualised management. Discussing every individual after detailed assessment in a multidisciplinary meeting is extremely important. Several studies have shown that elderly patients with gynecological malignancies are not treated to the same extent as young-er patients and have lower odds of receiving standard care according to the oncological protocols. Individualization of management in these patients could be identified in several studies in the literature showing that increasing age at diagnosis predicts deviation from guidelines for surgical therapy, adjuvant radiotherapy or chemotherapy. The authors performed a literature review to clarify whether there are any changes in the treatment of such patients, and whether their management should be considered to be individualized, depending on their age and comorbidities.

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DOI: 10.3897/folmed.62.e47831

Authors: Georgios Dryllis, Panagiota Liakou, Marianna Politou

Abstract: Pregnancy short- or long-term complications may involve the mother’s health, the fetus’s health, or both. A systematic literature review was performed, including studies up to October 2018 from Medline (PubMed), Science Direct, Web of Science and Google Scholar. The following inclusion criteria were applied: studies published until 2018 concerning the genetic background of pregnancy complications such as high blood pressure, gestational diabetes, preeclampsia, pregnancy loss, endometrial death, placental abruption, premature labor, and intrauterine growth retardation which may render pregnancy a high risk condition.We identified 164 articles that met the inclusion criteria and reviewed and analyzed them. The results so far are contradictory and the pathogenicity of these pregnancy complications remains unclear. For most of the polymorphisms studied so far, data refer to small studies size but research is on-going.The identification of genetic polymorphisms with strong correlations with certain pregnancy complications could provide us with useful tools which could be incorporated in diagnostic algorithms that could facilitate early detection and treatment of major pregnancy complications.

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DOI: 10.3897/folmed.62.e47875

Authors: Nikolaos Blontzos, Christos Iavazzo, Eirini Giovannopoulou, George Galanopoulos, Victoria Psomiadou, George Vorgias

Abstract: Primary peritoneal serous carcinoma (PPSC) is a rare malignancy, the clinical characteristics of which resemble ovarian serous carcinoma. We present a rare case of PPSC detected by an abnormal cervical smear, the first one with an absence of ovarian tissue at the time of the initial diagnosis.A 59-year-old asymptomatic woman presented with glandular atypia on routine Papanicolaou smear. Endocervical and endometrial curettage showed an adenocarcinoma with focal squamous differentiation and uncertain further classification. The patient had a past surgical history of bilateral salpingoophorectomy due to endometriosis. Abdominal MRI depicted omental multinodularity, great amount of ascites and possible endometrial tumor. The patient underwent total hysterectomy, omentectomy and biopsies of implants on Douglass pouch. Surgical and histological findings were consistent with primary peritoneal serous carcinoma. Abnormal pap smear could rarely be suggestive of extrauterine malignancies, such as peritoneal cancer.

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