Faculty of Medicine

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Echocardiographic Heart Changes in Pregnancies Complicated with Gestation Hypertension and Preeclampsia
(International Scientific Invention Journals, 2019-02-13)
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Milkovski, Daniel
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Introduction: Echocardiography as an imaging method is increasingly being used in obstetrics in the management of hemodynamic changes which occur in normal but also in pregnancies with gestational hypertension/preeclampsia. Aim: The aim of the study is to show that some of the heart changes in pregnancies complicated with gestational hypertension and preeclampsia are abnormal and further follow up of these patients is needed. Methods: A total of 81 patients were enrolled in the study. The patients were further divided in two groups. Pregnant women with gestational hypertension or preeclampsia (51) and a control group of normotensive pregnancies (30). A total of 3 echocardiograph exam were made, the first upon entry in the study (28 -34 g.w), the second 2 weeks after delivery and the last 6 months after delivery. Results and discussion: We found several statistically significant results that involve the IVS, PWLV, LKM, left chamber hypertrophy and diastolic function. Diastolic dysfunction usually shows up before systolic dysfunction in the evolution of ischemic/hypertensive cardiovascular disease and is of prognostic value in predicting long term cardiovascular morbidity. The changes seen 6 months after delivery on our last control mean that those changes are permanent and need further prevention strategies. Conclusion: From the noninvasive methods echocardiography is the most favorable method in identifying structural changes and functional changes in pregnancies with hypertension. Echocardiography allows fast, reproducible information and is both safe for mother and fetus.
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Chorangioma of placenta: single center analysis
(Wiley, 2022-10)
Kochoska, Milka
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Kochmanovska Petreska, Svetlana
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Ristovski, Grigor
Background: The most common benign neoplasms of the placenta are non-trophoblastic tumours. They include chorioangioma, teratoma, leiomyoma and hepatocellular adenoma. Chorioangioma is the most common subtype. The incidence of chorangioma is 0.5–1.0%. Small chorangiomas are clinically insignificant. Giant chorioangioma is rare tumours, measuring more than 4 cm in diameter and seen in association with elderly primi, twin pregnancy, hypertension, diabetics, and female fetus. Giant chorioangioma is associated with complications that can affect the mother, fetus, or neonate. Aims: This is a retrospective study of chorangioma cases seen at Institute of Pathology, Medical faculty, Skopje during a 10-year period from 2012 to 2021. Methods: Macroscopic findings, gestational weeks at delivery, maternal age and outcome of pregnancy were evaluated. Histological and immunochistochemical analyses of the placental chorangiomas were preformed. Results & Conclusions: In period of 10 years 6 causes of placental chorangioma were clinically identified and histopathologically confirmed. Four cases were giant chorangiomas measuring from 8 to 13 cm. One of the cases was identified as chorangioma of the umbilical cord. Three of the cases shows potential maternal risk factors like primary infertility, extreme obesity and post COVID status. The median gestational age of delivery was 33 + 6 weeks and 39.6 weeks, respectively. The maternal age range was between 25 to 34 years. Four of the pregnancies had favourable outcome with no complications during and after birth. One was with foetal distress and one with premature delivery. Microscopic examination of the mass showed numerous proliferative thin walled capillaries lined by f lattened endothelium and separated by fibrous stroma. This was further confirmed by IHC for CD34, which showed strong reactivity of endothelial cells.
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A rare case of pleomorphic dermal sarcoma presented during pregnancy, a case report
(John Wiley & Sons, Inc., 2024)
Milkovski, Daniel
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Gjirevski, Vlatko
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Kijajova, Ivana
Soft tissue sarcomas are rare tumors arising in mesenchymal tissues and can occur almost anywhere in the body. They are rarely diagnosed during pregnancy. Pleomorphic dermal sarcoma (PDS) are dermal-based malignant tumors that usually present on sun-exposed sites of elderly patients and are morphologically similar to atypical fibroxanthoma (AFX). PDS is considered an aggressive cancer and likely to metastasize and reappear. Early detection and aggressive treatment improve outcomes.
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DIASTOLIC DYSFUNCTION IN GESTATIONAL HYPERTENSION/ PREECLAMPSIA
(DEPARTMENT OF ANAESTHESIA AND REANIMATION, FACULTY OF MEDICINE, “SS. CYRIL AND METHODIUS” UNIVERSITY, SKOPJE, MACEDONIA, 2024-03)
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Milkovski, Daniel
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Introduction: Hypertensive disorders in pregnancy including preeclampsia are present in 10% of pregnancies and are one of the biggest reasons for both maternal and fetal morbidity and mortality. Materials and Methods: The study was undertaken at the University Clinic for Gynecology and Obstetrics in Skopje, North Macedonia. After initial assessment, 81 patients were enrolled in the study after signing a written consent. Patients were divided into two groups depending on whether they had hypertension or not. In the hypertensive group 51 patients were enrolled and 30 normotensive pregnancies were used as controls. Results: Based on the values of the parameters of diastolic function obtained with PDA of the transmittance flow and the values of the parameters obtained with TDI of the longitudinal movement of the mitral ring, diastolic dysfunction was found in 17 (33.2%) pregnant women of the studied population, LV function (p <0.001). In the pregnant women from the examined group in whom the presence of LV diastolic dysfunction was identified, the disorders were of mild degree, that is type of delayed relaxation of LV in all 17 pregnant women. Conclusion: Early recognition and management of symptoms are essential. Women who suffer from hypertensive disorders in pregnancy require close monitoring after delivery.
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CORRELATION BETWEEN SFLT/PLGF RATIO HIGHER THAN 200 AND ALTERED LABORATORY PARAMETARS OF PREECLAMPSIA IN HOSPITAL SETTINGS PATIENTS
(SHMSHM - AAMD, 2024)
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Milkovski, Daniel
Preeclampsia affects 2–7% of all pregnancies. Worldwide it is responsible for 500,000 fetal/neonatal deaths and 70,000 maternal deaths every year. Anti-angiogenic factor, soluble fms-like tyrosine kinase 1 (sFlt-1) and the pro-angiogenic factor, placental growth factor (PlGF) are usefull markers for screening, diagnosis and prognosis of preeclampsia. Aim: To show our experience about the correlation between angiogenic levels and laboratory blood and urine parametars in hospital settings patients with preeclampsia. Material and methods : Retrospective clinical study was performed in 2 years period. One hundred pregnant women with preeclampsia hospitalized in University clinic for obstetrics and gynecology in peripartal intensive care unite were evaluated .SFLT/PLGF ratio (Elecsys sFlt-1 and PlGF immunoassays), differential blood count, AST, ALT, LDH, uric acid, urine analysis (qualitative, quantitative proteinuria) were evaluated in all patients. Questionaire about sociodemographic data, age, parity, BMI, poor obstetric history, cigarette smoking, use of Aspirin or Clexane during actual pregnancy was taken during admission. Related to the sFlt-1/PIGF ratio (< 200 or ≥ 200) women were divided into two groups with 50% participants each. Results: Our patients with SFLT/PLGF ratio >200 were significantly younger, had significantly higher proteinuria (++,+++ and quantitative), had significantly higher levels of LDH and AST and were admitted at hospital treatment at significantly lower gestational week compared to ratio < 200.
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SMALL INTESTINE INTUSSUSCEPTION DUE TO GASTROINTESTINAL STROMAL TUMOUR IN PREGNANCY: A CASE REPORT
(Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, 2022)
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Simonovska Paneva, Iva
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Gastrointestinal stromal tumour (GIST) is very rare in pregnancy and only a few cases have been described in the literature. We present a case of a 38-year-old primigravida, presented with non-specific symptoms for the first time in the second trimester. Due to the non-specificity of the symptoms on one hand and the rarity of the tumour on the other, it took a long time for the final diagnosis to be made. Accidentally, on a routine obstetric ultrasound examination, a solid tumour formation was observed, localized under the lower pole of the left kidney. On MRI of the abdomen, in front of the left kidney there was a tubular structure, in close relation with small intestine, suspected for intussusception. At 28 weeks of gestation, an exploratory laparotomy was performed with resection of the involved part of the jejunum and TT anastomosis. Pregnancy was terminated electively, by caesarean section, in 38+6 gestational weeks. The clinical presentation of the GIST depends on the primary location of the tumour. Due to the extremely rare occurrence of these tumours in pregnancy, there is no solid scientific evidence for the most appropriate time of their treatment and the time of termination of pregnancy. The biggest challenge in pregnancy is timely diagnosis and treatment, without impact on the foetus. A multidisciplinary approach is needed. In our case, the severity of the mother’s symptoms outweighed the danger to the foetus from general anaesthesia and surgery itself.
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#1081 Evaluation of urinary dysfunction after nerve-sparing radical hysterectomy in patients with cervical cancer
(BMJ Publishing Group Ltd, 2023-09)
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Milkovski, Daniel
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Gjirevski, Vlatko
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Kijajova, Ivana
Introduction/Background: Urinary dysfunction is one of the most frequently described postoperative complications after radical hysterectomy. Extensive dissection leads to damage to the pelvic autonomic nerves that innervate the bladder muscles, urethral sphincter and pelvic floor fascia, and thus to urinary dysfunction. The aim of this study is to assess the length of the recovery phase and functional establishment of urinary function after radical hysterectomy type C1. Methodology It is a retrospective cross-sectional study conducted at the University of Gynecology and Obstetrics in the period from January to December 2022 in a total of 33 patients with cervical cancer (stage IA-IIA2) treated with radical hysterectomy. Postoperatively, urinary function was determined by measuring residual urine after appropriate training on the 5th-7th day, a residual volume below 100ml was considered as limit value for well-established urinary function. Results: The average age of the patients in the study was 51 years, the youngest patient was 29 years old, and the oldest 73 years old. The calculated mean length of urinary function recovery was 7.3±1.9 days, with a mean measured residual urine volume of 40.6±26.3 ml. Average time of hospital treatment is 7.7±2.41 days, but no longer than 14 days. Conclusion Monitoring the recovery phase and establishment of urinary function after radical hysterectomy is essential. Good surgical technique with maximum nerve preservation leads to early establishment of urinary function, removal of the urinary catheter and additional urinary complications prevention, shorter hospital stay and better quality of life for patients.
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Leiomyosarcoma of the vagina: A case report
(2022-05)
Bajdevska Dukovska, Daniela
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Milkovski, Daniel
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Objective: Primary malignant tumors of the vagina represent only about 2% of all gynecological malignancies. Primary vaginal sarcomas account for about 2% of all malignant vaginal lesions, with leiomyosarcomas being the most common form of malignant vaginal mesenchymal tumors. Case report: We present a case of a 49-year-old woman who was admitted to the University Clinic of Obstetrics and Gynecology complaining of vaginal discharge, abdominal pain and vaginal bleeding within 8 months. Ultrasound and MR showed a solid tumor infiltrating the posterior wall of the vagina. Complete surgical excision of tumor was accomplished. The operative material was composed of two lobulated, solid tumor masses with a total weight of 192 g, with dimensions 11x7x2,5-4cm and 7x5x2cm. The cut surface of the tumor showed nonencapsulated, gray-white glistening mass with hemorrhagic and necrotic areas. The tissue specimens were fixed in 10% buffered formalin and embedded in paraffin. Immunostainings with antibodies against Vimentin, SMA, CD10, S100, Desmin, CD99, Caldesmon, Podoplanin, CKAE1/AE3 and CD31 were made. Histologically, this tumor was composed of spindle-shaped cells with blunt-ended nuclei, arranged in storiform pattern with marked pleomorphism and nuclear atypia. Many bizarre cells and multinucleated cells were also seen. There were large regions of coagulative necrosis and high mitotic rate (27 per 10 HPF). Immunohistochemically, the tumor cells were positive for Vimentin, SMA, CD10 and negative for S100, Desmin, CD99, Caldesmon, Podoplanin, CKAE1/AE3 and CD31. The Ki67 proliferative index was 40%. A final diagnosis of high grade leiomyosarcoma was made. Postoperatively, the patient received adjuvant chemotherapy with gemcitabine and docetaxel for eight cycles. The tumor showed a progressive growth with distant metastasis to liver and paraortal and retroperitoneal lymph nodes. The patient died of the disease 9 months after diagnosis. Conclusion: Vaginal leiomyosarcoma is an extremely rare disease with very poor prognosis in advanced stages and undetermined ideal treatment regimen. Reporting rare tumors contributes to collecting data for rare neoplasms in order for proper early diagnosis and adequate therapy to be established.
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ROBSON CLASSIFICATION OF CESAREAN SECTION IN NORTH MACEDONIA - CURRENT TRENDS
(Македонско лекарско друштво = Macedonian medical association, 2021)
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Dalipi, Adelina
Abstract Introduction. Over the last few decades, the global cesarean section rate has significantly increased and reached an unprecedented level. The World Health Organization (WHO) has advised that cesarean section (CS) rates should not rise above 15%. Several classify¬cation systems have been proposed to tackle the increased cesarean section epidemic. Most of the countries have adopted and started using the Robson (10 groups) classification as the best and the one that is the easiest internationally applicable CS classification. Aim. To present the Robson classification as a way to start better classification of cesarean section and hence to reduce the number of unnecessary cesarean section deliveries. Methods: This study was realized at the University Clinic for Gynecology and Obstetrics in Skopje, North Macedonia. It is a retrospective study where two years were compared. Results. The rate of cesarean sections for 2017 was 38.5% and for 2019 42.6%. Categorization of deliveries according to Robson criteria showed a different rate of cesarean section for each subgroup. Discussion. The implementation of the Robson classi-fication in most countries has shown a reduction in the number of cesarean deliveries and thus a reduction in overall maternal and neonatal morbidity and mortality. The analysis has shown that group 5 had the largest number of cesarean section deliveries in both years, 2017 and 2019; these were patients with previous cesarean sections. They were followed by group 1 and 2, or pri¬mi¬para with spontaneous onset and induced delivery. Conclusion. The goal of Robson clasification is to identify the target groups that contribute most in the percentage of cesarean sections and to act on these tar-get groups through appropriate education and training.
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Acute appendicitis in the third trimester of a pregnancy finished with spontaneous vaginal delivery
(Asclepius, 2018)
Milkovski, Daniel
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Acute appendicitis is the most common surgical problem occurring during pregnancy. Its incidence is more common in the second trimester and is confirmed in 1/1000 pregnancies. Clinical manifestations of acute appendicitis in pregnant patients are generally very similar to non- pregnant patients. We present, here, the case of a 29-year-old pregnant patient at 35+4 weeks of gestation with the signs of acute appendicitis. The patient underwent a successful open appendectomy of her perforated appendix, without performing a cesarean section (CS) at the same time. 5 weeks postoperatively, at term, labor was induced with vaginal prostaglandins and the patient delivered a healthy female baby without any complications. Immediate diagnosis of acute appendicitis during pregnancy is recommended and management with the suitable surgical intervention should not be delayed for >24 h as it increases the risk of perforation with its subsequent critical complications. The treatment of acute appendicitis is always surgical, with an appendectomy and perioperative broad-spectrum antibiotics. Except in cases of high maternal and fetal mortality, a CS should not be done simultaneously with the appendectomy in cases of a perforated appendix with diffuse peritonitis, due to the very high risk of dehiscence of the uterus.

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