[Doctors specialty training in obstetrics and gynecology at university medical schools: 2012-2013]. / Specializacní vzdelávání v gynekologii a porodnictví na lékarských fakultách: 2012-2013.

OBJECTIVE: The paper addresses transfer of doctors specialty training from the national Institute of postgraduate medical education (IPVZ) to University Medical Schools (UMS) with the special focus to Obstetrics and Gynecology (OG). METHODS: The National Specialty Board (NSB) has been established. NSB tasks include definition of inclusion criteria and process of specialty choice at UMS. In OG specialty there are defined mid-term and final postgraduate training courses and other requirements for final specialty exam (FSE) - in particular trainees scientific work and surgery done with the supervision of NTB member. The system of FSE, its content, application, reimbursement and mechanisms are described in details. RESULTS: In the whole country in 2012 there have been done 864 FSE in all basic medical specialties, which took place at seven UMS. Autumn semester terms has been utilized significantly more than spring terms (57% vs. 43%). There have been differences in the numbers of specialties and also numbers of candidates in each specialty among different UMS. In total 94% of applicants succeed in the FSE. In 2012 within OG specialty training there has been held 56 FSE - 24 exams on five UMS in spring term and 32 (57%) exams only on two UMS in autumn term. In the spring 2013 FSE were organized on 1st LF UK in Prague with 23 applicants, from which 22 successfully passed. During autumn 2013 the FSE in OG will be held on LF UP in Olomouc with 44 applicants for final postgraduate training course and 39 candidates for FSE. CONCLUSION: Within OG specialty the transfer of doctors specialty training from IPVZ to UMS has been successfully managed. The NSB in OG specialty closely cooperates with past IPVZ and the Accreditation Commission of the Czech Ministry of Health. Thus continuity, quality and continuous enhancement of specialty training program in OG in Czech Republic is assured.

[HE4 a biomarker of ovarian cancer]. / HE4 - biomarker ovariálního karcinomu.

OBJECTIVE: Verification of the importance of determination of HE4 and calculation of ROMA index for increasing the efficiency of diagnosis of ovarian cancer in a population of Czech women. DESIGN: Prospective study. SETTING: Department of Gynaecology and Obstetrics, Faculty Hospital in Pilsen. METHODS: In the period from 06/24/2010 to 12/01/2011 was at the Department of Gynaecology and Obstetrics, University Hospital Pilsen examined 552 patients with abnormalities in the pelvis. Patients were divided into two groups. There were 30 women with histologically confirmed malignant ovarian tumors. Another 522 women had benign findings. According to the levels of FSH were women in both groups divided into premenopausal and postmenopausal. At all women were measured CA 125, HE4 and FSH. HE4 and CA125 were determined using the chemiluminescent device Architect 1000 (Abbott, USA), FSH chemiluminescent method on the device DXI 800 (Beckman Coulter, USA). At all premenopausal women was calculated ROMA1 index and at all postmenopausal women ROMA2 index. SAS statistical software 9.2 were used for all statistical calculations. RESULTS: The highest diagnostic efficiency was achieved by a combination of HE4 and CA125 markers with the calculation ROMA2 index for postmenopausal women. In determining of menopausal status according to the values of FSH cut-off for menopause 40 IU/L and cut-off at 26.4% for ROMA2 reaches ROMA2 sensitivity of 92.3%, specificity of 88.5% and PV- of 99.3%. If we reduce the cut-off for laboratory diagnosis of menopause using FSH at 22 IU/L, and cut-off for ROMA2 was 26.3% reaches ROMA2 sensitivity of 95.2%, specificity of 87.8% and PV- of 99.5%. CONCLUSION: HE4 in combination with CA125 and current ROMA index calculation is a suitable methodology to improve the detection of ovarian cancer.

[Epidemiology of genital warts in female population of Czech Republic]. / Epidemiologie genitálních bradavic mezi zenami v Ceské republice.

OBJECTIVE: The aim of study was to evaluate prevalence of genital warts in Czech Republic. SUBJECT: Multicentric prospective observation study. SETTING: HPV College. METHODS: During 6 month (February 2010 - July 2010) 20 private gynaecological centers in all Czech Republic were counting up the number of genital warts cases. Risk factors, therapy and knowledges about genital warts were evaluated. RESULTS: There were 637 patients with genital warts in cohort of 70 980 patients. The prevalence of genital warts was 0.89%. The most frequent risk factor was cigarette smoking in 37%. Main strategy for treatment were podophyllin local application and cold knife excision. CONCLUSION: The prevalence of genital warts in our study has shown importance for its prevention by rules of safety sex and HPV vaccination against HPV type 6 and 11.

[Repair of the 3rd and 4th degree obstetric perineal tear]. / Sutura ruptury perinea 3. a 4.stupne.

OBJECTIVE: Summary of the current knowledge of repair of obstetric anal sphincter trauma. DESIGN: Review. SETTING: Department of Gynecology and Obstetrics, Charles University and University Hospital Pilsen. SUMMARY: Review of the current international literature covering the given problem. RCOG classification of obstetrics perineal trauma should always be used as it respects the anatomic structures together with the physiological functions of tissue involved in ano-rectal continence. Two types of procedure: end-to-end approximation and overlapping of torn ends of the anal sphincter are both referred to and they are discussed with regards to the functional outcome of the repair. OPERATING CONDITIONS: Experience of the surgeon, operating theatre and its equipment, asepsis, lighting, operating instruments, anesthesia, material and type of suture, medication is described to increase the effectiveness of the repair. A delay in primary repair of up to 8-12 hours does not seem to be detrimental to the functional outcome of the procedure. Uncommon types of injury mentioned: segmented tear of internal anal sphincter, lateral tear of external anal sphincter.

[Delivery, and anal incontinence later in life]. / Porodní poranení a anální inkontinence v dlouhodobé perspektive.

OBJECTIVE: Evaluation of the mutual relationship between delivery and late anal incontinence. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen. SUMMARY: Anal incontinence is a symptom often referred to by women between the ages of 40 and 60. However, it seems, that only a small number of such cases might be related to obstetric perineal trauma. According to recent data, elective Caesarean section only plays a small protective role. Its effect is restricted to the first few years after delivery. With time, the function of the anal sphincter gradually deteriorates. Subsequent deliveries might contribute to this functional impairment. The long-term effect of forceps delivery is still not clear. The extent of anal sphincter trauma (particularly the defect of the internal anal sphincter) seems to have an impact on the development of anal incontinence, even years after the event. Overlooking defects of the anal sphincter is a cause of problems long after delivery. Given the unsatisfactory results of secondary overlapping, and also, relatively good preliminary effect of primary repair, careful observence of the recommended steps leading to the correct diagnostics of obstetric perineal trauma is crucial, as is adequate repair.

History of incidence of autoimmune and oncological diseases in identical female twins.

PROBLEM: The aim of study was to investigate identical female twins born in 1977 suffered from autoimmune diseases (twin A - Sjogren's syndrome, and twin B - systemic lupus erythematosus). METHOD OF STUDY: It was refer retrospective analysis of both sisters suffered beside autoimmune alterations (Sjogren's syndrome and systemic lupus erythematosus) also from gynecological diseases (twin A - praecancerosis of cervix uteri, twin B - carcinoma vaginae). RESULTS: Relationships between disease activities and severities in the female twins were similar and the treatments were directed according to clinical symptoms and laboratory results. Dramatic change, unfortunately, occurred with twin B. The reason may be the association between SLE activity (lupus nephritis), hematological complication (leukopenia) and oncological vaginal recidivation. CONCLUSION: Association between autoimmune disease and gynecological cancer (or praecancerosis) is major risk than without immunology deviation. Twin A is periodically gynecologically observed.

Leukaemia inhibitory factor (LIF) gene mutations in women diagnosed with unexplained infertility and endometriosis have a negative impact on the IVF outcome. A pilot study.

The frequency of functionally relevant mutations of the leukaemia inhibitory factor (LIF) gene in infertile women is significantly enhanced in comparison with fertile controls. The objective of this retrospective cohort study was to evaluate the impact of LIF gene mutations on the outcome of the treatment in women with various causes of infertility. Fifteen infertile women with the G to A transition at position 3400 leading to the valine to methionine exchange at codon 64 were analysed. Group A was made up of women with diagnoses that are frequently accompanied by changes in humoral as well as cell-mediated immunity - idiopathic infertility and endometriosis (N = 7). Group B consisted of patients with polycystic ovary syndrome (PCOS), andrological factor, tubal factor and hyperprolactinaemia (N = 8). The control group comprised 136 infertile women with no LIF gene mutation diagnosed with idiopathic infertility and endometriosis (N = 37) (group C) and patients with PCOS, tubal and andrological factor (N = 99) (group D). Seven of the mutation-positive patients were successfully treated by in vitro fertilization (IVF), but nobody in this group was diagnosed with idiopathic infertility and only one with endometriosis, which means that there is a statistically significant difference in the pregnancy rates between groups A and B (P = 0.01, Fisher's 2 by 2 exact test) but no statistically significant difference when comparing patients with the LIF gene mutation (group A+B) to no LIF gene mutation (group C+D). The results suggest that in mutation-positive women the idiopathic infertility and endometriosis have a negative impact on the outcome of IVF treatment.

[Mediolateral episiotomy and anal sphincter trauma]. / Mediolaterální epiziotomie a poranení análního sfinkteru.

OBJECTIVE: A summary of recent knowledge of the correlation between mediolateral episiotomy and anal sphincter injury. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen. CONCLUSIONS: The methodology of most studies is not well managed. Four problematical points were identified: definition of the mediolateral episiotomy, practical execution of the mediolateral episiotomy, diagnostics of perineal trauma and classification of the perineal trauma. Mediolateral episiotomy is often deficiently defined. Definitions differ depending on individual textbooks or departments. The majority of studies gives no definition and no description of the practical execution of an episiotomy or describes it inadequately. To the current knowledge there is no international consensual definition, which is used universally. Until 2003, there was no study evaluating adequate implementation of the mediolateral episiotomy. It appears that most of executed mediolateral episiotomies are not truly mediolateral. The angle of inclination between 40-60 degrees was suggested. According to the latest study, the lower limit of the mediolateral episiotomy definition (40 degrees) appears to be insufficient. At the present time, the correlation between mediolateral episiotomy and perineal trauma cannot be precisely evaluated. Before analyzing the benefits and risks of mediolateral episiotomy, an international consensus must be found, that would establish an exact definition of mediolateral episiotomy.

[Vascular complications of laparoscopic operations in gynaecology]. / Poranení velkých cév v gynekologické endoskopii.

OBJECTIVE: To provide information about vascular complications of laparoscopic operations in gynaecology. TYPE OF STUDY: Literature review and case reports. SETTING: Department of Gynaecology and Obstetrics, Medical faculty, Charles University, Pilsen. METHODS: Review of literature concerning vascular complications during laparoscopic operations in gynecology and case reports to illustrate the topic. CONCLUSION: Laparoscopic operations are benefiting for patiens. Vascular complications are rare, but their progression is often fatal even for young patients. When such complications occur, their quick treatment is crucial and co-operation with a anaesthesiologist and vascular surgeon is needed.

[Caesarean section and anal incontinence]. / Cisarský rez a anální inkontinence.

OBJECTIVE: Summary of the impact of Caesarean section on anal incontinence. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Plzen. SUMMARY: Review of the current international literature. Currently, Caesarean section is not considered to reduce symptoms of anal incontinence. If there is any reduction of symptoms, that remains only for a short term (40% in 3 months after the delivery in the largest trial). In a long term, virtually in no trial has been observed any difference, and others, non-obstetrical factors (particularly aging) prevail. Current knowledge does not allow to assess sufficiently pros and cons of Caesarean compared to vaginal delivery. High risk groups, that would profit from elective Ceasarean, have not been clearly identified yet.

[Maternal position at the delivery and perineal trauma]. / Poloha matky pri porodu a poranení perinea.

OBJECTIVE: Summary of the relation between of maternal position at the delivery and obstetrical perineal trauma. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and Faculty Hospital Plzen. SUMMARY: Positions of mother at the delivery are divided in to: supine, semi-recumbent, lithotomy, lateral and upright positions - standing, sitting, squatting and kneeling. Birthing chair or stool might be applied. Outlined potential benefit of upright positions. So far there was not observed any consented negative impact of upright position on a mother or a child. Its potential positive effect has not been proved. A reduction of episiotomy, a slight increase in the second degree tears and more frequent blood lost over 500 mls has been described. The risk of anal sphincter trauma has been studied insufficiently. It appears, the different positions might involve different risks of the third degree tear. Up to now there is no reason to discourage woman from some of upright positions. Anyway she must be fully informed of a limited support and protection of perineum in an effort to reduce the risk of anal sphincter injury.

[Occult anal sphincter tear--up-to-date knowledge]. / Okultní ruptura análního sfinkteru behem porodu--soucasné znalosti.

OBJECTIVE: Summary of the current knowledge of sonographically and clinically detectable anal sphincter injury. DESIGN: Review. SETTING: Department of Gynaecology and Obstetrics, Charles University and University Hospital Pilsen. SUMMARY: Review of the current international literature covering the given problem. Occult anal sphincter tear is defined as an injury, which is clinically undetectable and recognizable just on endoanal ultrasonography. Total frequence of anal sphincter defects detected by sonography varies between 19-67%. At any rate majority of them likely seem to be injuries which are clinically detectable, however undiagnosed and missed. Isolated defect of internal anal sphincter is an example of real occult anal sphincter injury. This is found in around 2% of all vaginal deliveries. A diligent digital examination of perineum after the delivery and a proper education of perineal anatomy is the cornerstone in improving of the diagnostics. Endoanal ultrasound may serve as a tool in facilitation of the diagnosis.

[How can the haematopoietic stem cells from the umbilical cord blood be de-differentiated in vitro? Our first results using the co-cultivation systems]. / Jak dediferencovat hematopoetické kmenové bunky z umbilikální krve in vitro? Nase první výsledky s pouzitím kokultivacních systému.

OBJECTIVE: Aim of this study was to de-differentiate the haematopoietic stem cells (HSCs) that originated from the umbilical cord blood. One of the ways to do it is to use a co-cultivation system. DESIGN: Prospective experimental study. SETTING: Laboratory study - Institute of reproductive medicine and endocrinology, Pilsen. METHODS: HSCs were co-cultivated with mouse embryonic stem cells (mESC) with and without feeder cells. After co-cultivation HSCs were analyzed using flow-cytometry for presence of haematopoietic markers (CD34, CD45, CD133) and using immunohistochemistry for presence of embryonic stem cell markers (SSEA-4, Tra-1-60, Tra-1-81). RESULTS: No de-differentiation was detectable in any our experiment, only the intensity of the HSC cell markers decreased. CONCLUSION: We suppose that there were two major reasons for the experiment failure: there was no direct cell to cell contact and there was a mixture of cell types that originated from two different species. To reach our goal of in vitro de-differentiation we will need to change our strategy towards a pure human culture system without any animal additives and with cell to cell contact.

[Are the antibodies against laminin-1 the signifikant marker of decreased fertility in women?]. / Jsou protilátky proti lamininu-1 významným markerem snízené plodnosti u zen?

OBJECTIVE: Study of antibodies against laminin-1 in IgG in patients with habitual abortion. DESIGN: Prospective study. METHODS: Commercial ELISA method for detection of IgG antibodies against laminin-1 in ovulatory cervical mucus, in sera in women with repeated spontaneous abortions, in sera in patients during spontaneous miscarriages. RESULTS: Positive levels of antibodies against laminine-1 in IgG in sera were found in patients during spontaneous abortions, as to ovulatory mucus of infertile women in time out of pregnancy, we did not find any positivity, only in one serum sample in patient with three pregnancy losses in her history. CONCLUSION: Antibodies against adhesive molecule as laminin-1 presents, can participate during diagnosis of repated spontaneous miscarriages in context of neuro-endocrinne-immune dysregulation, which is not seen during physiological pregnancy.

[The leukemia inhibitory factor gene mutations in the population of infertile women: the heterozygote transition G to A on the position 3400 does not affect the outcome of the infertility treatment]. / Mutace v genu pro leukemický inhibicní faktor v populaci neplodných zen: heterozygotní bodová zámena G za A na pozici 3400 neovlivnuje úspesnost lécby.

OBJECTIVE: The leukemia inhibitory factor (LIF) is one of the most important signaling factors in the embryo-maternal cross talk during the embryo implantation. We investigated the prevalence of the LIF gene mutations in the population of infertile women and their impact on infertility treatment. DESIGN: A cohort study. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine and University Hospital of Charles University, Pilsen. SUBJECTS AND METHODS: The population to screen consisted of 399 infertile women. The control population was comprised of 202 healthy fertile subjects. For the mutational analysis, the temperature gradient gel electrophoresis (TGGE) followed by subsequent sequencing of the positive samples, had been used. The groups of fertile controls and infertile patients were compared for statistically significant difference using the Fisher's 2 by 2 Exact test. RESULTS: Twelve potentially functional LIF gene mutations, the G to A transversion at the position 3400 leading to the valin to methionin exchange at codon 64 (V64M) were detected in the group of infertile women. No mutations were identified in the control group, which means that the frequency of functionally relevant mutations of the LIF gene in infertile women is significantly enhanced in comparison with controls (P = 0.01, Fisher's 2 by 2 Exact test ). Seven of these patients were successfully treated by in vitro fertilization (IVF). CONCLUSION: The results suggest that the LIF gene mutation, the heterozygote G to A transition on the position 3400, affects fertility but the infertility treatment can succeed. Even though LIF gene mutations occur infrequently and can be overcome by infertility treatment, their impact on molecular events during early phases of pregnancy should be further elucidated.

Association of the leukemia inhibitory factor gene mutation and the antiphospholipid antibodies in the peripheral blood of infertile women.

To characterize the impact of the potentially functional mutation--the G to A transition at the position 3400 of the leukemia inhibitory factor (LIF; a pluripotent cytokine that plays a central role in the control of the embryo implantation) gene that leads to the exchange of valine with methionine at codon 64 we evaluated the association of the LIF gene mutation and the levels of antiphospolipid antibodies (aPLs) in the peripheral blood of infertile women (the aPLs examination was part of our routine immunological test during the infertility check-up). Eight infertile mutation-positive women were diagnosed with idiopathic infertility (n=5) and endometriosis (n=3) and their levels of aPLs in serum were compared with 115 infertile women without any LIF gene mutation. Enzyme-linked immunosorbent assay was used for the detection of seven antiphospholipid antibodies; the results were statistically assessed by the Fisher's 2 by 2 exact test to evaluate the association of the LIF gene mutations and aPLs in serum of infertile patients. The presence of aPLs was significantly higher in our study group (100%) than in 30% of aPLs-positives in control infertile patients (p = 0.0035) which indicates that the aPLs are elevated in women with LIF gene mutations.

[How exact is the performance of mediolateral episiotomy]. / Jak presné je provedení mediolaterální epiziotomie.

OBJECTIVE: Evaluation of correctly performed mediolateral episiotomies in vaginal deliveries. METHODS: A cohort study of 253 primigravid women after their first vaginal delivery. The main parameter followed was the angle of episiotomy. This is defined as the angle formed by midline and the line of epidermal suturing of the episiotomy. RESULTS: 137 women had deliveries performed by a doctor and 116 by a midwife. There was no significant difference between groups. The number of adequately performed mediolateral episiotomies was 100 (40%) altogether, from them 48 (41%) among midwives and 52 (40%) among doctors. Other parameters were: the length of perineum, the length of episiotomy, and the shortest distance between episiotomy and the centre of the anus. CONCLUSION: This study shows that majority of episiotomies are cut in the wrong direction. The difference in technique between doctors and midwives was not observed.