Risk of anal incontinence in women with inflammatory bowel diseases after delivery.

AIM: The aim of our prospective study was to evaluate the development of postpartum anal incontinence in patients with inflammatory bowel disease (IBD) compared to healthy women. MATERIAL AND METHODS: Patients with IBD and healthy controls enrolled in the study from January 1st 2013 to November 30th 2016 and filled in the anal incontinence questionnaire in the beginning of pregnancy and after vaginal delivery. The results were statistically processed using suitable tests. RESULTS: A total of 57 women were enrolled, 17 (29.8 %) with ulcerative colitis, 23 (40.4 %) with Crohn's disease, and 17 (29.8 %) healthy controls. Incidence of postpartum anal incontinence is comparable across all groups; there was no statistically significant difference between the IBD and control groups (Kruskal-Wallis test by ranks with Dunn correction, non-significant). Postpartum anal incontinence was strongly correlated with the extent of perineal injury (r = 0.80; p < 0.0001; Pearson's linear correlation). CONCLUSIONS: Women with inflammatory bowel disease in remission do not exhibit higher incidence of postpartum anal incontinence (PPAI) compared to healthy controls; the key correlate of PPAI appears to be the extent of obstetric injury, consistently across all study groups. These results suggest that concerns about postpartum anal incontinence development should not be an indication for Caesarean section in IBD patients (Tab. 6, Fig. 1, Ref. 34).

[Ritgen maneuver and its modifications]. / Ritgenuv manévr a jeho modifikace.

OBJECTIVE: To present the Ritgen maneuver, its original description as well as its most common modifications and to demonstrate the heterogenity of descriptions of the maneuver regarding its performance, purpose and published results. DESIGN: A review article. SETTING: Department of Gynecology and Obstetrics, Medical Faculty and University Hospital Pilsen, Charles University in Prague. METHODS: A review article demonstrating the heterogeneity of Ritgen maneuver descriptions based on analysis of present and past obstetrical textbooks and journal articles. CONCLUSION: At present there is a pursuit of finding and analysis of methods for obstetric perineal injury prevention, which could considerably improve quality of life of women after delivery. One of the possible mechanisms of perineal trauma reduction is to ensure that the fetal head passes with its smallest head circumference through the perineal structures. Already in the middle of the 19th century, von Ritgen devised a method allowing to facilitate and control the extension of the fetal head in the end of the second stage of labor. His method quickly spread all over the world, however, the description changed considerably. The Ritgen maneuver today means a variety often very different interventions. This review points out to the need of clarification of terminology, i.e. definition and classification of methods facilitating extension of the fetal head in the end of the second stage of labor.

[Gitelman syndrome in pregnancy--a severe hypokalemia with favorable perinatal prognosis]. / Gitelmanuv syndrom v tehotenství - tezká hypokalémie s príznivou perinatální prognózou.

Gitelman syndrom is a rare congenital tubulopathy characterized by hypokalemia, hypomagnesemia, metabolic alkalosis and hypocalciuria. We report a case of a 32-year-old patient admitted for asymptomatic hypokalemia and hypomagnesemia in the 30th week of gestation. A diagnosis of Gitelman syndrom was made and intravenous administration of potassium chloride in high doses combined with spironolactone was started. Despite intensive potassium supplementation (8 g/day), the serum potassium levels remained at the lower limit of normality throughout the pregnancy. The patient delivered a healthy female 2670 g/48 cm after labor induction in the 39th week of gestation. A summary of 22 so far published cases of Gitelman syndrome in pregnancy is presented. The analysis of published case studies suggests a need for ion supplementation, reduction of urinary potassium wasting, monitoring of fetal well-being and amniotic fluid levels. Pregnancy has a very favorable perinatal prognosis despite critical serum levels of potassium and magnesium throughout the pregnancy.

[Perineal audit: reasons for more than one thousand episiotomies]. / Perineální audit: duvody pro více nez 1000 epiziotomií.

AIM: To analyze reasons for episiotomy use in vaginal delivery among obstetricians and midwives. Consecutively, to indentify disputable indications for its use based on published research in order to facilitate the decrease in frequency of this operation, while preserving high quality of obstetrical care. METHODS: Reasons for mediolateral episiotomy use were recorded by obstetricians and midwives after each vaginal delivery with episiotomy at the Ob&Gyn Department of the Charles University Hospital in Pilsen in the period of February 2006 - June 2007. The main reason and all reasons for episiotomy use were evaluated separately. RESULTS: The reason for episiotomy use was recorded in 1069 cases (93%) out of a total of 1150 vaginal deliveries, in which mediolateral episiotomy was performed (42% of all vaginal deliveries). The most common group of main reasons for episiotomy use was a concern about postpartum pelvic floor functional impairment (624, 58% of episiotomies), especially a rigid, non-elastic perineum (401, 37%). Fetal distress (181, 17%) and abnormalities of the expulsive forces/uncooperative parturient (109, 10%) followed. When evaluating all (including secondary) reasons, the most common groups of reasons for episiotomy use were the effort of pelvic floor functionality preservation (871, 50%), abnormalities of the expulsive forces/uncooperative parturient (354, 20%) and fetal distress (253, 15%). When evaluating episiotomies performed by obstetricians and midwives separately, the concern about postpartum pelvic floor functionality prevailed in midwives (81% vs. 39% of episiotomies performed primarily for this reason). Conversely, the obstetricians performed episiotomy more frequently for fetal distress (28% vs. 4%). CONCLUSION: In view of the fact that midwives attend only physiological deliveries in our department, the spectrum of reasons for episiotomy use among midwives is narrower and the concern about postpartum pelvic floor functionality dominates. Currently, the concern about postpartum pelvic floor functionality should not be considered a legitimate indication for episiotomy use. The fact that 624 (58%) episiotomies were performed for this reason represents a significant reserve for a decrease in the frequency of episiotomy use. The reduction should be possible primarily among midwives (81% of all main reasons for episiotomy use in the midwive group, i.e. 37% of all episiotomies performed). The analysis of reasons for episiotomy use is an important step in reduction of episiotomy rates while preserving or improving the standard of treatment provided.

[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.

[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.

[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.

Phenotypic and morphological characterization of in vitro oligodendrogliogenesis.

The neurosphere assay has been used to maintain neural progenitor cells (NPCs) in the undifferentiated state. These cells are multipotent and gave rise to neurons and glial cells. Here we show that within 10 days of culture, neurospheres contained precursors and differentiated progeny of all three major central nervous system (CNS) cell lineages and these occupied distinct zones. The microenvironment of the inner zone supported cell differentiation. Cells of oligodendroglial lineage generated within the neurosphere were frequently observed. Of these cells, A2B5(+) cells were homogeneously distributed in the neurospheres, NG2(+) cells preferentially occupied the outer zone and O4(+) cells were localized at the inner zone of 10 day-old neurospheres. We prevented a massive cell death of dissociated neurosphere cells seen after differentiation triggered with adhesion and fetal calf serum by adding epidermal growth factor and basic fibroblast growth factor to the culture medium. Under these conditions, less than one third of cells did not express cell specific markers, glial fibrillary acidic protein-positive astroglia represented 43.4%, NG2(+) and/or O4(+) oligodendroglia represented 24.3%, and betaIII-tubulin(+) neurons 3.1% of cells recovered after neurosphere differentiation. We present evidence that oligodendroglial cells differentiate in a stepwise process as a result of their distribution in subsets that represent distinct developmental stages according to antigenic and morphological criteria. These include oligodendrocyte progenitors, preoligodendrocytes, and oligodendrocytes. The highly complex morphology of mature oligodendrocytes was compatible with functional cells.

[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.

Foetal mouse neural stem cells give rise to ependymal cells in vitro.

NSCs are responsible for the generation of CNS cell types derived from the neural tube. Published data resulting from experiments studying the differentiation of NSCs in vitro or in vivo have confirmed their spontaneous tripotency, i.e. their ability to generate cells of the neuronal, astroglial and oligodendroglial lineages. The relationship between NSCs generated in vitro and ependymal cells has not yet been studied. To confirm that ependymal cells can also be produced by NSCs, we utilized the neurosphere assay, which permits isolation and cultivation of NSCs. Cells from the forebrain of E14-15 Balb/c foetuses were grown in DMEM/F12-N2 medium supplemented with EGF and FGF-2 to form multicellular neurospheres. After 3 to 8 passages, neurospheres were plated on surfaces coated with poly-L-lysine, polyornithine and/or laminin in dishes containing the same medium where cytokines were replaced with serum. Under these conditions, neurosphere cells spread over the surface forming a cellular layer consisting of beta-III tubulin+ neuronal, GFAP+ astroglial and O4+ oligodendroglial cells. When these cells were cultivated for prolonged periods, they formed islands of epitheloid cells. Following 2 to 3 weeks in vitro, ependymal cells with beating cilia appeared among these cells. Ciliated ependymal cells were observed in small clusters or as single cells scattered in certain areas. Confocal microscopy confirmed the presence of alpha-tubulin-immunoreactive cilia arranged in tufts located on the apical surface of epitheloid cells. Our data indicate that ependymal cells are spontaneously derived from NSCs.

Differentiation potential of murine neural stem cells in vitro and after transplantation.

We examined the differentiation potential of murine neural stem cells (NSCs) grown in vitro and transplanted into intact and irradiated recipients. NSCs were isolated from neonatal Balb/c mice using the neurosphere assay. On in vitro differentiation assays, NSCs produced beta-III tubulin(+) neurons, glial fibrillary acidic protein (GFAP(+)) astrocytes, and O4(+) oligodendrocytes. After neural grafting to histocompatible adult mice, NSCs gave rise to neuronal and glial cells. When cells were transplanted in the form of solid neurospheres, they reached terminal differentiation and spatial arrangements that mimicked the three-dimensional organization of nervous tissue. To create conditions that would allow us to assess the potential for generation of nonneural cells, NSCs were intravenously injected into irradiated mice. Transplantation of NSCs stimulated hematopoiesis because the number of colony-forming units of granulocyte-monocyte lineage (CFU-GM) colonies isolated from the spleen and bone marrow of transplanted mice was greater than that from irradiated, nontransplanted animals. Moreover, transplanted cells tagged with beta-galactosidase were identified in the thymus of animals grafted with labelled NSCs. NSCs harvested from the neurosphere assay produced viable and transplantable cells. In vitro differentiation assays and neural grafting confirmed the multipotency of NSCs and their commitment to generate neuronal and glial cells. Following intravenous injection of NSCs, the transplanted cells colonized hematopoietic and lymphatic organs, facilitating hematopoiesis in irradiated animals.

The transplantation of neural stem cells and predictive factors in hematopoietic recovery in irradiated mice.

A number of surprising observations have shown that stem cells, in suitable conditions, have the ability to produce a whole spectrum of cell types, regardless, whether these tissues are derived from the same germ layer or not. This phenomenon is called stem cell plasticity, which means that tissue-specific stem cells are mutually interchangeable. In our experiments, as a model, we used neural stem cells (NSCs) harvested from fetal (E14-15) neocortex and beta-galactosidase positive. In the first experiment we found that on days 12 and 30 after sub-lethal irradiation (LD 8.5 Gy) and (beta-galactosidase(+)) NSCs transplantation all mice survived, just as the group with bone marrow transplantation. Moreover, the bone marrow of mice transplanted NSCs contained the number of CFU-GM colonies with beta-galactosidase(+) cells which was as much as 50% higher. These differences were statistically significant, p<0.001. In the second experiment, we studied kinetics of (beta-galactosidase(+)) NSCs after their transplantation to sub-lethally irradiated mice. Histochemistry of tissues was performed on days 12 and 30 post-transplantation, and beta-galactosidase(+) cells were detected with the help of histochemical examination of removed tissues (lung, liver, spleen, thymus, and skeletal muscle). In tissues removed on day 12 post-transplantation, we found a significantly higher number of beta-galactosidase(+) cells in the spleen and thymus on day 30. While we presumed the presence beta-galactosidase(+) cells in the spleen, as spleen and reticuloendothelial system represent an important retaining system for different cell types, the presence of beta-galactosidase(+) cells in the thymus was rather surprising but very interesting. This indicates a certain mutual and close interconnection of transplanted stem cells and immune system in an adult organism. In the third experiment, we verified the mutual interchange of Sca-1 surface antigen in the bone marrow cells and NSCs before transplantation. Analysis of this antigen showed 24.8% Sca-1 positive cells among the bone marrow cells, while NSCs were Sca-1 negative. Our experiments show that NSCs share hemopoietic identity and may significantly influence the recovery of damaged hematopoiesis but do not have typical superficial markers as HSCs. This result is important for the determination of predictive factors for hemopoiesis recovery, for stem cell plasticity and for their use in the cell therapy.

Local environmental factors determine hematopoietic differentiation of neural stem cells.

Stem cells exhibit unique properties and hold high therapeutic promise, but factors influencing their differentiation after transplantation need to be recognized and defined for this promise to be fully met. Here, we demonstrate that endogenous colony-forming unit spleen (CFU-S) colonies are not generated in lethally irradiated mice transplanted with neural stem cells obtained from brain tissue of syngeneic donors. We investigated the proportion of transplanted neural stem cells that contributed to hematopoietic reconstitution and compared the distribution of transplanted cells in nonsplenectomized to that of splenectomized mice following sublethal whole-body irradiation. We also used clonogenic assays, colony assays, and histochemical analyses to explore conditions under which transplanted, beta-galactosidase-tagged neural stem cells underwent hematopoietic differentiation. Our results suggest that neural stem cells do undergo extramedullary hematopoiesis, even while no endogenous hematopoietic colonies develop in the spleen. Furthermore, we found that neural stem cells effectively colonized the bone marrow of splectomized recipients. We conclude that the hematopoietic differentiation of neural stem cells is highly dependent on the extramedullary environment. We also conclude that the bone marrow does not provide an environment supportive of hematopoietic differentiation by neural stem cells.

Biocompatibility of HEMA copolymers designed for treatment of CNS diseases with polymer-encapsulated cells.

Surrounding the cells with a semipermeable polymeric membrane allows transplanting unmatched xenogeneic cells without a risk of their rejection. We prepared and tested several 2-hydroxyethyl methacrylate (HEMA) copolymers with alkyl methacrylates or acrylates to find out which was the most valuable for cell encapsulation. On the basis of optimum physical properties and good results of cytotoxicity tests, HEMA-EMA copolymer was chosen as a suitable candidate for encapsulation and immunoprotection of xenogeneic cells before their grafting into the central nervous system (CNS). To characterize the biocompatibility of p(HEMA-co-EMA) copolymer in the CNS, we implanted microcapsules made of this hydrogel into the brains of adult rats that were allowed to survive for 0.5, 1, 3, 6, and 9 months. Analysis of histological sections containing the implantation site was aimed at assessment of the cellular density at the implant-brain interface and identification of cell types participating in a tissue reaction. Our results indicated that the tissue reaction that was observed was caused largely by the implantation procedure because HLA-DR- and GSI-B4-positive macrophages/microglia infiltrated mainly the implantation channel. The number of these cells declined with time, which was true also for GFAP-positive reactive astrocytes, as well as for foreign body giant cells. The amount of connective tissue components surrounding the implanted microcapsules increased only slightly. These findings indicated that p(HEMA-co-EMA) hydrogel was well tolerated after implantation in the brain.