[Office hysteroscopy - management and results]. / Management a výsledky ambulantní hysteroskopie.

OBJECTIVE: Sum up the knowledge about office hysteroscopy. TYPE OF STUDY: Review of literature and our own experience. SETTING: Department of Gynaecology and Obstetrics, First Faculty of Medicine, Charles University Prague and General Teaching Hospital Prague. METHODS: Data from scientific literature and 10 years of our own experience with office hysteroscopy. CONCLUSIONS: Hysteroscopy provides optical evaluation of uterine cavity. Most of the benign intrauterine organics pathologies could be managed in a outpatient setting with a vaginoscopic approach without any anaesthesia and analgesia. Using that approach we can recommend to perform endometrial target biopsy, resection of endometrial polyps up to 1.5 cm and pedunculated submucous myomas up to 1 cm as well as resection of filmy intrauterine adhesions. Method is comfortable for well managed patients and practically complication-free.

[Endometriosis]. / Endometrióza.

OBJECTIVE: To summarize current knowledge of pathogenesis, diagnostics and treatment of endometriosis. DESIGN: Review article. SETTING: Centre for diagnostics and treatment of endometriosis, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Faculty of Medicine of Charles University, Prague. METHODS AND RESULTS: Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. The condition is predominantly found in women of reproductive age, from all ethnic and social groups. The associated symptoms - pain, infertility - can impact on general physical, mental and social well being. Treatment must be individualised, taking the clinical problem in its entirety into account, including the impact of the disease and the effect of its treatment on quality of life. Pain symptoms may persist despite seemingly adequate medical and/or surgical treatment of the disease. In such circumstances, a multi-disciplinary approach involving a pain clinic and counselling should be considered early in the treatment plan. CONCLUSION: Endometriosis is a medical condition with high recurrence rate and especially those patients with deep infiltrating endometriosis should be centralized to the centres experienced in diagnostics, complicated surgical treatment and providing multi-disciplinary approach with adequate postoperative care.

Uterine arteries doppler velocimetry provides 3-years follow up endometrial ablation outcome.

The aim of this study was to assess whether uterine artery Doppler velocimetry [pulsatility index (PI) and resistance index (RI)] and thickness of the endometrium (TE) are able to predict 3-year clinical outcome after endometrial ablation (EA) for dysfunctional uterine bleeding (DUB). This was a prospective, observational study of 29 women of whom 22 were amenorrhoeic (A) and 7 eumenorrhoeic (E) at the end of the first postoperative year. The PI, RI and TE were measured prior to and 1, 6 and 12 months after EA. Statistical analyses were performed using BMDP statistical software, discriminant analysis, ANOVA and T test. Using the calculated classification function (CF) with the three parameters PI, RI and TE measured 12 months after FEAT, we were able to accurately (100%) specify which of the women will have A or E in 3 years. The predictive value of PI, RI and TE has been confirmed clinically in a minimum 3-year follow-up of outcome (ranging from 36 to 72 months [mean 55]). All A and E women have stayed in the same group (A or E) during the minimum of 3 years. In conclusion we found that PI, RI and TE measured prior to EA cannot predict the outcome, however these measurements performed 1 year after FEAT can predict the duration of A or E in the 3-year follow up.

[Long-term follow-up after complete treatment of peritoneal endometriosis with the CO2 laser]. / Dlouhodobé follow-up po kompletním osetrení peritoneální endometriózy CO2 laserem.

OBJECTIVE: To evaluate the effect of laparoscopic CO2 laser ablation of peritoneal endometriosis in the treatment of pelvic pain with a long-term follow-up. To differentiate the effect of surgery on different types of pelvic pain. DESIGN: Prospective observational study. SETTING: Department of Obstetrics and Gynecology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague. METHODS: Patients with 1st to 3rd stage endometriosis, with manifestation of pelvic pain, and with complete excision of peritoneal endometriosis lesions, were included in the study. All visible lesions were vaporized by CO2 laser following adhesiolysis and complete visualization of the pelvis. After the procedure, patients were followed up at 6-month intervals. The severity of pelipathia, dyspareunia, dysmenorrhea, pain during micturition, and pain during defecation were monitored using a visual analog score of 10 points. RESULTS: A total of 31 patients were included in the study. After 6, 12, and 18 months after surgery, the recurrence of pelvic pain was found in 12 (39%), 15 (48%), and 19 (61%) patients, respectively. Improvement or disappearance of complaints was documented 18 months after the surgery in 11 cases of dysmenorrhea (50%), 9 cases of dyspareunia (50%), 14 cases of pelipathia (58%), 12 cases of pain during micturition (71%), and in 14 cases of pain during defecation (87.5%). The proportion of recurrences increases with the length of the interval after the procedure, mainly in dysmenorrhea and dyspareunia. CONCLUSIONS: The effect (improvement or disappearance of pelvic pain) of a complete CO2 laser ablation of peritoneal endometriosis continues 18 months after the surgery in about 40% of patients. A graduated increase in the number of recurrences is apparent during follow-up, most significantly in dysmenorrhea and dyspareunia. The effect of surgery on different types of pelvic pain varies. A small number of recurrences was found in pain during micturition and pain during defecation, on the other hand, less success was apparent in the treatment of dysmenorrhea.

[Initial experience with the Versapoint bipolar electrode in hysteroscopic tissue vaporization]. / Nase první zkusenosti s bipolární elektrodou Versapoint k hysteroskopické vaporizaci tkání.

OBJECTIVE: To evaluate our first experience with bipolar electrode (Verspoint, Johnson&Johnson) for transcervical surgery. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynecology, 1st medical Faculty, Charles University, Prague. METHODS: Twenty procedures with bipolar electrode in normal saline as distension fluid were performed between September and November 1999. All 20 patients underwent office diagnostic hysteroscopy with biopsy sampling which demonstrated benign histological finding. We used Olympus operative 7 mm hysteroscope, Versapoint system with bipolar electrodes (twizle, spring, ball). In 13 cases we vaporized intrauterine polyps, in 4 cases we vaporized intrauterine submucous myoma (grade I-ESH), in 1 case we dissected intrauterine septum and in 2 cases we performed intrauterine adhesiolysis. Local anesthesia-paracervical block was employed in 50% of procedures and general anesthesia was employed in 50% of cases. RESULTS: The surgeon evaluated the degree of difficulty during the procedure as comfortable and easy to use in case of intrauterine polyp, intrauterine septum and intrauterine adhesions vaporisation, as mild difficulty in submucous myoma to 2 cm and moderate/severe difficulty in case of myoma vaporisation of more than 2 cm size. No complications were registered during or post procedure, we did not registered no sign of hyponatremia, no complains regarding pain or discomfort from patients. CONCLUSION: The advantage of Versapoint bipolar system for intrauterine operative hysteroscopy is the use of normal saline as distention fluid, which decreases pre and postoperative complications. We evaluated the vaporisation of pedunculate intrauterine pathologies up to 2 cm as comfortable and easy to use. Combined to local anesthesia it appears to be a useful system for office hysteroscopy and transcervical surgery.

[[Endometrial ablation--prospective 5-year follow-up study]. / Ablace endometria--prospektivní 5letá "follow up" studie.

OBJECTIVE: Objective of the study is to evaluate the effectiveness of endometrial ablation in patients with persistent uterine bleeding who are unresponsive to conservative therapy. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and Gynaecology, 1st Medical Faculty, Charles University and General Faculty Hospital in Prague, Czech Republic. METHODS: 100 women with intractable uterine bleeding were subjected to undergo endometrial ablation. 44 patients were treated preoperatively not only with danazol or progestins but also with Norethisteron acetas to stop the acute bleeding preoperatively and 65 gave no preoperative drug administration. Under appropriate anesthesia the cervix was dilated to 100 mm and the uterine cavity was distended with Purisol (Sorbitol and Manitol). Roller-ball coagulation technique combined with loop highfrequency endoresection was used in most of the patients (85 patients). The findings of small uterine myoma(s) were not consider as a contraindication of the endometrial ablation. RESULTS: At 51-2 months 42 (42%) of patients reported amenorrhea, 51 (51%) hypomenorrhea, 5 (5%) eumenorrhea and 2 (2%) nochange. The mean time to complete operation was 30 minutes (range 15-45 minutes). The procedure was completed in all 100 women and we had no serious complications. CONCLUSION: It is concluded, that endometrial ablation is safe and effective hysteroscopic procedure in the cases of abnormal uterine bleeding for women with normal uterine morfological findings or small uterine myoma(s) considering the follow up 51-2 month of the study.

[Ambulatory hysteroscopy--a new trend in the diagnosis and treatment of intrauterine pathology]. / Ambulantní hysteroskopie--nový trend v diagnostice a resení intrauterinních patologií.

OBJECTIVE: An analysis of ambulatory hysteroscopic procedures. DESIGN: Retrospective study. SETTING: Dept. of Obstetrics and Gynecology of the 1st Faculty of Medicine, Charles University and the General Faculty Hospital, Apolinárská 18, Prague 2, Czech Republic. METHODS: The sample consists of 225 patients who underwent ambulatory hysteroscopy, during the period between September 1999 to February 2000. The sample makes up 46.3% of the total number of hysteroscopies performed during that period. The procedures were performed under a paracervical block, only rarely in combination with analgesic sedation. RESULTS: Indications for the procedure were most often abnormal uterine bleeding peri- or postmenopausally, 51.2%, abnormal ultrasound findings in 9.8%, and endometrial polyps in 1.8%. In only 23.11% of cases, hysteroscopy was performed in the frame of TCS (transcervical surgery), the remaining procedures were diagnostic. The paracervical block was a great benefit to the comfort of the ambulatory procedures. In 93%, the procedure was evaluated as comfortable, in 4.8% there was discomfort, and in only 2.2% general anesthesia was used due to significant pain. We did not observe any early or late complications. CONCLUSION: Hysteroscopy can be performed as an ambulatory procedure, assuming quality equipment, an experienced surgeon, and properly administered local anesthesia. Our results demonstrate that hysteroscopy is not only a diagnostic procedure, but can be used for certain procedures in the area of TCS (with low or intermediate level of difficulty).

[Termination of 128 pregnancies in the 2nd trimester using prostaglandin 15 methyl F2 alpha]. / Ukoncení 128 tehotenství ve II. trimestru gravidity aplikací prostaglandinu 15 metyl F2alfa.

OBJECTIVE: The critical analysis of the authors' standard protocol of termination of pregnancy during the second trimester. DESIGN: The prospective nonrandomised study. SETTING: Department of Gynecology and Obstetrics, 1th Faculty of Medicine, Prague. METHODS: We used a synthetic prostaglandin analog carboprost, 15-methyl-prostaglandin F2 alpha for induction of abortion during second trimester. It was administered in a single dose 500 micrograms. It was given into the amniotic cavity through the transabdominal puncture. At the same time dinoprostonum gel (0.5 mg) was given into vagine. Peridural analgesia has used since beginning of contractions. We investigated indication, mean period of induction, correlation between the period and indication and week of pregnancy so as a type and number of complication. RESULTS: From October 1998 till January 2000 128 pregnancy were terminated by intraamniotic prostaglandins administration. After a single administration 67.2% of women aborted within 24 hours. In 32.8% the intraamniotic administration was repeated twice. The mean induction period, i.e. the interval between the administration and abortion of the foetus was 28 hours. We didn't detect a correlation between the period of induction and the week of gestation or indication. COMPLICATIONS: A major blood loss replaced by transfusion of erythrocyte mass at 4 cases, a rest in uterus at 3 cases, once perforation of uterus during revision of the uterine cavity, once sectio minor for bleeding, once major bleeding conjoined with septic shock, once phlebotrombosis and at three headache (in connection with peridural analgesia). CONCLUSION: The therapeutic effect was achieved in all instances. One case of sectio minor was connected with strong vaginal bleeding. The method fulfils condition for second-trimester termination of pregnancy--must be safe, rapid, psychologically feasible and associated with a minimal risk of long-term consequences. The disadvantage of the method is the price of prostaglandins and necessity to repeat administration in 32.8% of patients.

[Hysteroscopic resection of submucosal myomas in abnormal uterine bleeding: results of a 4-year prospective study]. / Hysteroskopická resekce submukózních myomu pri abnormálním delozním krvácení: výsledky ctyrleté prospektivní studie.

OBJECTIVE: The evaluation of the effect of transcervical resection of submucous myoma/s in patients with abnormal uterine bleeding. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and Gynaecology, 1st Medical Faculty, Charles University and General Faculty Hospital in Prague, Czech Republic. METHODS: 45 patients with resected submucous myoma/s within the period 1995-1998 were selected. Patients in whom resection of myoma was combined with endometrial ablation were excluded. The average age of the cohort was 43 years (29-53). In 37 patients (82%) therapeutical curettage was performed for severe bleeding in the past (3 procedures on average, interval 1-7). In 16 patients (36%) transfusion was administered in the treatment of anaemia secondary to abnormal uterine bleeding in the past. Hysteroscopy, ultrasound scan or both techniques were used to diagnose and classify myomas. In 39 patients 1 myoma was resected, in 6 patients 2 myomas. In 12 (27%) patients myoma of 0., in 29 (64%) of I. and in 4 (9%) of II. has been diagnosed according to the ESH classification. In case of several myomas, the classification was based on the one of the highest degree. Surgery was performed in the early proliferative phase of the menstrual cycle. Purisol (sorbitol and mannitol) was used as a distension medium. Myomas were resected using loop high frequency electroendoresection technique. In 3 (7%) patients myomas of ESH II. were resected in more steps--in 2 cases (5%) in 2 steps and in 1 case (2%) in 3 steps. In patients with myomas classified as a 0. and I., only the character of menstrual cycle has been monitored after surgery. Ultrasound investigation was performed in patients with myomas of II. 3 months after surgery. RESULTS: The bleeding was controlled in terms of eumenorrhoea or hypomenorrhoea in all 45 patients (100%). Ultrasound investigation showed no residual myoma in any of 4 patients after resection of II. myoma. One case fluid overload syndrome of minor degree was documented as the only complication. CONCLUSION: Hysteroscopic high frequency endorsection is a safe and effective method and method of choice in the treatment of submucous myomas in patients with abnormal uterine bleeding. The high success rate in our cohort is certainly influenced by the number of patients included and by the length of follow-up.

[Cleft lip and palate--prenatal diagnosis and counseling]. / Rozstep rtu a patra--prenatální diagnostika a poradenství.

The most frequent congenital developmental defect in the orofacial region are, no doubt, facial clefts which are a serious stress for health professionals and the population. Depending on the type of cleft, the prevalence is between 1 : 1000-2800 births. According to contemporary views in the etiology of orofacial clefts participate genetic as well as environmental factors. That means that specific genetic factors create a certain "sensitivity" for specific factors of the external environment which act as a trigger mechanism and combined they produce the cleft. Cleft lip can be diagnosed already during the 13th week of gestation, while a cleft palate is not necessarily apparent till after the 18th week of gestation as the maxilla is in the process of joining. Presentation of the foetal face and its profile is thus important in particular during the second trimester of gestation and should be part of ultrasonographic screening between the 18th and 20th week of gestation. As more than 8% of facial clefts are associated with chromosomal abnormalities, in all affected foetuses karyotyping is done. The prognosis of satisfactory cosmetic and functional repair in cleft lip and in cleft lip and palate is favourable. In case of associated malformations all depends on the type and severity of these associated defects or on the diagnosis of the syndrome. If median clefts are extensive or associated with cerebral anomalies, the prognosis is as a rule poor. Prenatal diagnosis and management of defects of the orofacial area calls for collaboration of the obstetrician, neonatologist and plastic surgeon already in the stage when the defect is detected to give the expectant mother an opportunity to obtain accurate and unbiased information on possible treatment and prognosis for the foetus.

[Termination of pregnancy in the 2nd trimester using intra-amniotic administration of prostaglandins]. / Ukoncení tehotenství ve II. trimestru gravidity intraamniální aplikací prostaglandinu.

INTRODUCTION: The method used to terminate pregnancy on medical grounds during the second trimester must be safe, rapid, psychologically feasible and associated with a minimal risk of long-term sequelae. The objective of the present work was a critical analysis of the author's standard protocol of termination of pregnancy during the second trimester. MATERIAL AND METHODS: For induction of abortion during the second trimester the authors used a synthetic prostaglandin analogue (PG) F2 alpha-Dinoprost which was administered in a single dose of 30 mg by the intraamniotic route. At the time of onset of uterine contractions the authors administered peridural anaesthesia. The authors investigated indications, mean period of induction, correlation between the period of induction of abortion and the indications for termination of pregnancy, the week of pregnancy and parity of the mother. They recorded also the type and number of complications. RESULTS: From January 1991 till June 1997 179 pregnancies were terminated by intraamniotic PG administration. After a single intraamniotic PG administration 72% women aborted within 24 hours. In 26% women the intraamniotic administration was repeated twice and in 2% women three times. The mean induction period, i.e. the interval between the administration and abortion of the foetus was 22.6 hours. The interval was significantly longer (28 hours) in foetuses where pregnancy was terminated because of a neural tube defect (p < 0.01). The authors did not detect a correlation between the period of induction and the indication, week of gestation and parity of the mother. COMPLICATIONS: once a general reaction to intraamniotic administration, in three patients a major blood loss replaced by transfusion of erythrocyte mass, no uterine rupture. CONCLUSION: In all instances the therapeutic effect was achieved and there was no need to perform section minor. The disadvantage of the method is the high price of the preparation and need of repeated intraamniotic administration of PG in 29% of the patients.

PIP: In this study F2 alpha-Dinoprost, a synthetic prostaglandin analogue, was tested for use in inducing abortion in second-trimester pregnancy. During the period of January 1991 to June 1997 a total of 179 pregnancies were terminated by intra-amniotic administration of the drug. The indications for the fetus were congenital abnormalities (59 cases or 32%), intrauterine death (41 cases or 24%), and chromosomal aberrations (20 cases or 11%). For the mother the indications were internal disease, psychological reasons (38 cases or 21%), and unsuccessful abortion in the first trimester. The following procedure was carried out: puncture of the amniotic sac under ultrasound control, intra- amniotic administration of a 5 mg of Dinoprost test dose followed by the whole single dose of 30 mg, continuous infusion of 5 mg of Dinoprost at a speed of 10 gtt/min, peridural analgesia, and instrumental curettage. Peridural anesthesia was administered at the time of onset of uterine contractions. Following a single dose 72 women aborted within 24 hours. The intra-amniotic administration of the drug was performed twice in 48 (26%) women and three times in 3 (2%) women. The mean induction period (the interval between dose administration and the expulsion of the fetus) was 22.6 hours. The interval was significantly longer (28 hours) in fetuses for which pregnancy was terminated because of a neural tube defect (p 0.01). Complications included 1 episode of general reaction to intra-amniotic administration; in 3 patients massive blood loss was replaced by the transfusion of 2 x 300 ml erythrocyte mass. Postabortum residue was encountered in 2 cases, cervical rupture in one case, and phlebothrombosis in 1 case. The disadvantage of the method is the high price of the preparation and, to judge by these results, that it requires repeated administration for a substantial minority (29% or 51) of patients.

[Diagnosis and therapy of erythrocyte alloimmunization in pregnancy]. / Diagnostika a lécba erytrocytární aloimunizace v tehotenství.

INTRODUCTION: By preventive administration of anti-D globulin the number of cases of Rh isoimmunization declines steadily. Severe untreated isoimmunization may lead via foetal hydrops to intrauterine death, sometimes already during the 18th-19th week of gestation. The purpose of prenatal diagnosis in pregnant women with isoimmunization is to assess the danger or affection of the foetus, its prognosis and the mode of monitoring of the foetus. It is necessary to decide in time on intrauterine therapy by transfusion of erythrocyte mass and to assess the optimal time of delivery with regard to the risk of prematurity and foetal erythroblastosis, as well as with regard to intrauterine therapy. The objective of the present work was to test the protocol in the treatment of erythrocytic isoimmunization of the foetus. METHOD: During the period between January 1991 and October 1997 the authors investigated two groups of pregnant women: with a hydropic (n = 5) and non-hydropic (n = 20) foetus at the onset of treatment. In both groups amniocentesis and umbilical puncture were indicated. The authors investigated the number of cordocenteses and the volume of transfused blood per pregnancy, the number of complications and their type, gestation age of the foetuses on delivery, their birth weight, the condition of the neonates after delivery and on discharge to home care. RESULTS: During the mentioned period the authors administered 70 intraumbilical transfusions to 25 foetuses. The transfusion was not repeated more than eight times. The baseline haematocrit of non-hydropic foetuses was 26 (14-34), treatment was started on average during the 28th week (23rd-33rd). Pregnancy in women with a non-hydropic foetus was terminated during the 35th (27th-40th) week, with a mean weight of the foetuses of 2439 g (870-3520). Of 25 treated foetuses 6 were hydropic (24%) at the onset of treatment. The initial haematocrit of hydropic foetuses was 10.7 (4-19.8), treatment was started on average during the 28th (23rd-33rd) week. Pregnancy of women with hydropic foetuses was terminated during the 30th (25th-36th) week, the mean birth weight being 1838 g (660-3500). DISCUSSION: The very favourable therapeutic results in non-hydropic foetuses are in great contrast with the therapeutic results of moribund hydropic foetuses. CONCLUSION: The basic prerequisite of successful treatment by intraumbilical transfusion is to concentrate risk pregnancies in specialized centres with a high standard neonatological team for intensive care of pathological neonates.

[Complications of prevention and treatment of erythrocyte alloimmunization (case reports)]. / Komplikace prevence a lécby erytrocytární aloimunizace (Kazuistiky).

OBJECTIVES: The treatment of late recognized alloimunization with intraumbilical transfusions is more difficult and more often connected with complications. MATERIAL AND METHOD: Between 1991-1997 we performed 70 intraumbilical transfusions in 25 fetuses for erythrocyte alloimunization. Six fetuses (24%) were hydropic in the beginning of the treatment. Eleven fetuses were delivered before 36 weeks of pregnancy. Two immature neonates (660 g and 1320 g) had intraventricular hemorrhage with neurologic complications. In six cases the transfusion was complicated by severe bradycardia of the fetus, but only twice the pregnancy was to be terminated by cesarean sectio during 24 hours after the procedure. Two of the 25 fetuses died antenataly and one postnataly, all of them primary hydropic. Two neonates had severe late onset anemia. CONCLUSION: Fetal alloimune anemia should be treated before onset of hydrops. The study was supported by the grant of IGA Ministry of Health CR No. 3200-3.

[Comparison of the DNA-GEN Probe PACE 2 method and the LCR method for the detection of Chlamydia trachomatis in the female genital tract]. / Srovnávací studie metodik DNA-GEN probe PACE 2 a LCR k prukazu Chlamydia trachomatis v zenském genitálním ústrojí.

OBJECTIVE: Comparison of two methods of so-called rapid assessment of Chlamydia trachomatis in the urogenital system, i.e. the hybridization method GEN-Probe PACE 2 and the amplification LCR (ligase chain reaction) method. In 1995-1996 the authors made a screening examination to detect Chlamydiae in the urogenital tract by means of the hybridization method GEN-Probe PACE 2 and the amplification LCR method in selected groups of patients of the Second Gynaecological and Obstetric Clinic, First Faculty Hospital, Prague. The methods were evaluated as to their sensitivity. The examinations of the samples were made in the serological laboratory of the First Dermatological Clinic of the First Faculty Hospital Charles University, Prague. The amplification method is twice as sensitive as the hybridization method.