[Chronic pelvic pain and combined oral hormonal contraception].

PURPOSE OF THE STUDY: To determine the frequency of usage of combined oral hormonal contraception/COHC/ and its efficiency in women with chronic pelvic pain/CPP/. MATERIALS AND METHODS: Three-hundred and seventy, consecutively admitted in the Clinic women with CPP, were included in the study. They were divided into 2 groups--group A/n = 80/--women that had used COHC, and group B/n = 290/--women that had not used COHC in order to cope with pain symptomatic. The patients from the both groups were compared according to their socio-demographic, menstrual and reproductive characteristics, type of disease, duration of CPP assessment of pain intensity and McGill pain indices, subjective rating of efficiency of the used COHC by the means of 5-rate scale in diseases, manifested with chronic pain symptomatic/leiomyoma /L/ endometriosis/E, pelvic congestion syndrome/PCS/, adhaesion syndrome/AS, Allen-Masters syndrome and other gynaecologic pathology/OGP/--chronic pelvic inflammatory disease/ CPID/, ovarian cysts /OC/, etc./. RESULTS AND DISCUSSION: Duration of CPP /in months/ was comparatively longer in group A /50,74 +/- 10,33/in comparison wit group B/41,38 +/- 5,97/. No significant difference was found in quantitative pain assessment, but in group A higher values of all pain indices/sensory, affective, total pain rating index/and of evaluative overall pain intensity of total pain experience were set, compared with those of group B. It was ascertained a bigger number of types of used medicines in group A/analgesics, spasmolytics, gestagenes and GnRH-agonists/. Efficiency of COHC was assessed by the patients in the range "good-/basically/very good-excellent", and that was well demonstrated by women with L, E, AS and OGP/CPID, etc./. CONCLUSION: COHC was administered to patients with more heavily demonstrated chronic pelvic pain symptomatic, that required combination of more than two medicines in order to obtain a better therapeutic effect. Diseases, manifesting with CPP like E, L and OGP/CPID, OC, AS, etc/are of great priority in treatment with COHC.

[Laparoscopic findings in women with chronic pelvic pain].

OBJECTIVE: To determine the frequency and analyze the findings during laparoscopy in women with chronic pelvic pain /CPP/. MATERIALS AND METHODS: The study was conducted in the period 01.03.2004-01.07.2007 in the Gynaecological clinic at the Department of Obstetrics and Gynaecology, MU-Pleven. Eighty-six women were consecutively admitted in the Clinic, presenting with pelvic pain with duration more than 6 months and who underwent laparoscopy in order to be diagnostically defined more accurately or operatively treated. They were classified according to their socio-demographic characteristics, reproductive history/fertility and parity/, presence of preceding operative interventions, and findings during laparoscopy. RESULTS AND DISCUSSION: The most frequent findings in women with CPP during laparoscopy were endometriosis /56,98%/ and adhaesion syndrome /39,53%/, and with a lower frequency-pelvic varicosis /17.44%/ and Allen-Masters syndrome /24,42%/. The most common localization of endometriotic foci was on ovaries/40,7%/and plica vesicouterina /18,6 %/, and of the varicose dilated veins-along vv.ovaricae and in the basis of the broad ligaments/resp. 89,96 and 60%/. CONCLUSION: Laparoscopy is an exceptionally valuable and useful method in diagnosing and differentiating the etiology of chronic pelvic pain symptoms, because of the frequent presence of more than one cause with pelvic localization for its appearance.

[Frequency of gynecological morbidity and chronic pelvic pain in the Gynecological Clinic, UMPHAT "Dr. G. Stransky" - Pleven].

OBJECTIVE: By setting the structure of gynaecological morbidity to determine the frequency of chronic pelvic pain /CPP/ and the most common diseases, presented with CPP. MATERIALS AND METHODS: A prospective study was conducted in the Gynaecological Clinic at the Department of Obstetrics and Gynaecology, Medical University-Pleven in the period 01.03.2004-01.07.2007. During that period, 4168 women were consecutively admitted in the Clinic. The object of the study were patients with leiomyomatosis /L/, endometriosis /E/, adenomyosis /A/, pelvic congestion syndrome/PCS/, Allen-Masters syndrome/AMS/, pelvic inflammatory disease /PID/ and adhesion syndrome /AS/. They were divided in groups according to age, type of disease and presence of CPP. The following methods were used for the purpose of the study: documentary method, R-AFS classification of E, inquiry method-by a questionnaire/form/, based on instruments for pain assessment, which are accepted worldwide /visual analogue scale, etc. RESULTS AND DISCUSSION: Among all 1357 women included in the study, the most common diseases were L, followed by E and A, and AS. Comparatively lower frequency was determined for PCS and AMS. In almost one-third of the women in the study were admitted in the Clinic for diagnostic specification or operative treatment because of CPP. The most frequently defined reason for it were E, L and AS, and in a smaller part of patients-PCS and AMS. CONCLUSION: From the analysis we made, we concluded that CPP was very often polyetiologically determined, which was assessed by some invasive methods.

[Therapeutical management of the most frequent gynaecological diseases and chronic pelvic pain in the Gynaecological Clinic, UMPHAT "Dr. G. Stransky"-Pleven in the period 2004-2007].

OBJECTIVE: To determine the trend in application of the basic therapeutical procedures in the most common gynaecological diseases combined or not with chronic pelvic pain /CPP/. MATERIALS AND METHODS: In the prospective study conducted in the Gynaecological Clinic at the Department of Obstetrics and Gynaecology, MU-Pleven in the period 01.03.2004-01.07.2007, 1356 women with leiomyomatosis /L/, endometriosis /E/, adenomyosis /A/, pelvic congestion syndrome /PCS/, Allen-Masters syndrome /AMS/, pelvic inflammatory disease /PID/ and adhaesion syndrome /AS/, were included in it. They were grouped according to their age, type of disease, presence of CPP, type of therapeutical procedure and histological verification of the condition. For the purpose of the study the following methods were used: documentary method, R-AFS classification of E, inquiry method-by a questionnaire /form/, based on instruments for pain assessment, accepted worldwide. RESULTS AND DISCUSSION: The highest frequency was determined for L, E and A, and AS. In the majority of the total number of consecutively admitted patients with those diseases an operative intervention was done, and almost one-sixth of women underwent conservative treatment. The same trend was observed in patients with chronic pain symptomatic, regarding their operative and conservative management. Histological verification of the condition was closely related with etiological reason and diagnostic approach. CONCLUSION: A balance between conservative and operative treatment should be set in the basis of therapeutical management, consistent with modern diagnostic procedures. Determination of the trend in treatment of women with CPP will lead to falling off of indiscriminate application of operative methods prior to exact diagnostic specification and setting of multidisciplinary approach. That will serve as a background for the future conduct to that group of patients.

[Comparison and analysis of pain profiles in women with endometriosis and pelvic congestion syndrome--part II].

PURPOSE OF THE STUDY: To compare and analyze the pain profiles of patients with endometriosis /E/, adenomyosis /A/, and pelvic congestion syndrome /PCS/ in order to specify the factors that make closer the profiles of these conditions, and the factors, that make the differences between them clearer. MATERIALS AND METHODS: A prospective study was conducted in the Clinic of Gynaecology, Department of Obstetrics and Gynaecology, Medical University-Pleven in the period 01.03.2004-01.02.2006. It included 98 patients consequently admitted in the Clinic--66 patients suspected of or with proven E, and 32 patients with PCS. For the purpose of the study the following methods were used: pain chart, visual-analogue scale /VAS/, monthly pain calendar, documentary method, R-AFS classification of endometriosis and inquiry method. RESULTS AND DISCUSSION: The object of interest in this study were the pain profiles of E, A and PCS, and the dependence and association of severity of manifestation of the particular components of the pelvic pain syndrome /dysmenorrhoea, dyspareunia, postcoital ache, etc./ of the conditions mentioned above, on: stage of endometriosis, localization of endometriotic foci, diameter of maximal dilation and location of varicosely altered pelvic veins in women with PCS. It was found that the intensity and specificity of component demonstration of pelvic pain syndrome of women with endometriosis were not dependent on the stage of the disease, but on location of endometriotic lesions. In patients with PCS the severity and specific character of chronic pain syndrome were dependent on diameter of maximal dilation and site of varicose pelvic veins. According to its characteristics, pain profile of women A takes a specific place between the peculiar profiles of patients with E and PCS.

[Comparison and analysis of pain profiles of women with endometriosis and pelvic congestion syndrome--part I].

UNLABELLED: Pain is a general symptom in the clinical evolution of endometriosis /E/, particularly of adenomyosis /A/, and pelvic congestion syndrome /PCS/-conditions with different incidence and contingent of women with specific characteristics. PURPOSE OF THE STUDY: To build up and compare the pain profiles of patients with E, A, and PCS by the use of quantitative and qualitative characteristics. MATERIALS AND METHODS: A prospective study was conducted in the Clinic of Gynaecology, Department of Obstetrics and Gynaecology, Medical University-Pleven in the period 01.03.2004-01.02.2006. It included 98 patients--66 consequently admitted in the Clinic patients /for diagnostic specification or operative treatment/, suspected of or with proven E, and 32 patients with PCS. For the purpose of the study the following methods were used: pain chart, visual-analogue scale /VAS/, monthly pain calendar, documentary method, R-AFS classification of endometriosis and inquiry method. RESULTS AND DISCUSSION: It was made a specification of and comparison between qualitative, quantitative and topical characteristics of chronic pelvic pain syndrome of women with E, A and PCS. Factors that aggravate and alleviate pain symptomatic were determined and the most frequent additional symptoms besides pain were pointed out. Discriminating between pain profiles of patients with E, A and PCS contributes to more precise differential-diagnostic specification together with other diagnostic means.

[Endometriosis and chronic pelvic pain].

UNLABELLED: Endometriosis /E/ is a frequently met disease in women in reproductive age. One of its most typical clinical manifestations is chronic pelvic pain /CPP/ and as components of the chronic pain syndrome- dysmenorrhoea, dyspareunia, intermenstrual pain, and sometimes dyschezia and dysuria. PURPOSE OF THE STUDY: To build up pain profile of patients with E by using quantitative and qualitative characteristics. MATERIALS AND METHODS: The study was conducted in the Clinic of Gynaecology at the Department of Obstetrics and Gynaecology, Medical University-Pleven in the period 01.03.2004-01.02.2006 Sixty-six patients were included in the study. They were consecutively admitted in the Clinic for diagnostic specification or operative treatment, and in whom E was suspected or proved before. The patients were grouped according their age, fertility, body mass index, blood group affiliation, stage of the disease, etc. The following methods were used for the purpose of the study: pain map, monthly pain calendar, inquiry method-by a questionnaire /form/, based on instruments for pain assessment, which are accepted worldwide; documentary method, R-AFS classification of E. Factors that provoke appearance and manifestation of pain, and factors that alleviate pain were studied too. RESULTS AND DISCUSSION: The obtained results were statistically processed and were presented by the means of tables, graphics and numerical quantities. They corroborated the hypothesis for typical pain profile of women with E. CONCLUSION: The building up of pain profile in total with other diagnostic methods /ultrasonography, magnetic resonance imaging/ has a determining role in the further diagnostic and therapeutic management of women with E and CPP. Pain profile can also be used as an assessment tool of conducted treatment /conservative or surgical/.

[Pain profile of women with endometriosis and chronic pelvic pain-determining factors and significance].

PURPOSE OF THE STUDY: To determine the severity of the separate components of chronic pelvic pain syndrome/dysmenorrhoea, dyspareunia, dysuria, dyschezia ,etc/ in the different stages of the disease and according to the localization of endometriotic lesions. To determine to what extent the severity of the separate chronic pain components correlates with stage of the disease and localization of endometriomas. MATERIALS AND METHODS: The study was conducted in the Clinic of Gynaecology at the Department of Obstetrics and Gynaecology, Medical University-Pleven in the period 01.03.2004 - 01.02.2006 Sixty-six patients were included in the study. They were consecutively admitted in the Clinic for diagnostic specification or operative treatment, and in whom E was suspected or proved before. The patients were grouped according their age, fertility, type of the disease - internal or external genital endometriosis, adenomyosis, stage of the disease, localization of endometriotic lesions. The following methods were used for the purpose of the study: visual analogue scale, documentary method, R-AFS classification of E, inquiry method-by a questionnaire /form/, based on instruments for pain assessment, which are accepted worldwide. RESULTS AND DISCUSSION: The obtained results were statistically processed and were presented by the means of tables, graphics and numerical quantities. When the mean value of pain assessment was reported, there was noted a non-correspondence between severity of pain and stage of the disease. It was found no significant correlation between the extent of manifestation of the separate components of the pain syndrome according to the stage of the disease. The severity of the separate components of the pain syndrome was determined according to the localization of the E-lesions. Statistically significant correlation was found between the extent of manifestation of dyspareunia, postcoital ache and dyschezia, and the localization of the E- lesions /p<0,05/ and that correlation was strongly supported in cases of adenomyosis and the components mentioned above. Statistically significant differences were found between the extent of manifestation of the relevant component of the chronic pain syndrome and some of the localization of E foci. CONCLUSION: It was established a correlation between localization of E lesions and the severity of the separate components of the chronic pain syndrome. No correlation was found between the extent of pain manifestation, when assessed in total and in each pain component, and the stage of endometriosis.

[Diagnostic approach to Allen-Masters syndrome].

UNLABELLED: In the basic appearance of chronic pelvic pain /CPP/, it is often found the symptomatology of Allen-Masters syndrome /AMS/, especially having in mind pelvic congestion syndrome /PCS/. PURPOSE OF INVESTIGATION: To determine the diagnostic approach to AMS on the basis of CPP and factors conducive to development of AMS. METHODS AND MATERIALS: A nine-year retro- and prospective study (in the period 1996-2004) was conducted in Gynaecological Clinic at the Department of Obstetrics and Gynaecology, Medical University - Pleven. Forty patients with verified AMS were included in it. A documentary and inquiry methods were used for the investigation purposes. The following conducive factors were studied: age, body mass index /BMI/, blood group belonging, deliveries, including that of macrosomic foetuses, abortions and other gynaecologic interventions. It was rendered an account of the beginning of CPP, its qualitative and quantitative characteristics, localization and irradiation, its dynamics according to menstrual cycle and day. Excel and Statgraphics plus for Windows were used for the statistical processing of the data obtained from the investigation. RESULTS: Major conducive factors to AMS are BMI, number of pregnancies (deliveries and abortions), weight/ body mass of baby born. CPP is clinically manifested with dysmenorrhoea, dyspareunia and postcoital ache. CONCLUSION: The determined specific pain profile and the presence of proved etiological factors, parallel with laparoscopic method, are auspicious means for diagnosing AMS.

[Iron-deficiency anaemia in everyday gynaecological practice]. / Zheliazo-defitsitnata anemiia v ezhednevnata ginekologichna praktika.

INTRODUCTION: Iron-deficiency anaemia /IDA/ is of utmost significance to clinical practice. Chronic haemorrhages from the genital tract are the major etiological factor for its appearance in 60-70% of the patients. Abnormal genital bleeding for the specialist in Obstetrics and gynaecology and IDA for the haematologist are frequently met problems in their everyday practice, which require detailed examination, good colaboration and synchronization between the work of both specialists. PURPOSE: Diagnosing and etiological treatment of IDA of gynaecologic origin by mutual timely and adequate co-operation of gynaecologist and haematologist. MATERIALS AND METHODS: Clinical survey based on the algorithm worked out. Its everyday application started in July-August 2001 and till today /30.04.2003/ 253 cases with IDA in the Department of Gynaecology are taken in. A record of proceedings was made for every patient and that helped the further diagnostic and therapeutic activity and respective data processing. RESULTS AND DISCUSSION: The data and results obtained verify the achievement of final diagnostic specification of IDA, the role of the algorithm as a stepping-stone to its etiological treatment, complete and durable correction of iron deficiency.

[Indications for third and more than three cesarean sections--analysis and pattern of practice]. / Indikatsii za treto i poveche ot tri tsezarovi secheniia--analiz, nasoki za povedenie.

PURPOSE OF THE STUDY: Authors aimed to analyse indications for third and more than three times cesarean sections (c. s.), as well as, to make an assessment of the adequacy of the taken decisions. METHODS AND MATERIALS: It was conducted a retrospective study for third and more than three times cesarean, including period 1991-2003 in the Department of Obstetrics and Gynaecology, Medical University, Pleven. During that time 28645 births has taken place, 2971 of which are by cesarean section. 2,5% from the last, has been third and more than three times cesarean. Using expert judging, indications for the last were divided into three groups-right, disputable and wrong. RESULTS: In the cases with only one mentioned indication "Re-re c.s." 37,8% (28 patients), ratio between right, disputable and wrong was 2:1:1 and the same ratio in the cases with indication "Re-re c.s.+ other indications" 58,1% (43 patients), was 5:1:1. In 4,3% of the cases (3 patients) no indication "Re-re c.s." was mentioned. CONCLUSION: Reduction of third and more than three times cesarean can be achieved by more careful judgement of indications in second, "disputable", group and erradication of the "wrong", which most commonly are jatrogenic reasons. This will result in diminishing the increasing frequency of abdominal births, as well as, preventing possible complications for mother, connected with operation.

[Leiomyomatosis and chronic pelvic pain]. / Leiomiomatoza i khronichna tazova bolka (predvaritelno suobshtenie).

UNLABELLED: Leiomyomatosis is one of the major gynaecological diseases, which cause the onset of chronic pelvic pain /CPP/. PURPOSE OF THE STUDY: To build up a pain profile of patients with leiomyoma by the use of quantitative and qualitative characteristics. METHODS AND MATERIALS: The study was conducted through the period of 01.01.2004-01.07.2004 in the Clinic of Gynaecology of the Department of Obstetrics and Gynaecology, Medical University-Pleven. During that period 94 patients with leiomyomatosis were admitted in the clinic, and they filled in an inquiry form, containing also a pain calendar and pain map. Clinical and pathohistological data, verifying type, localization and clinical manifestation were used too. RESULTS AND DISCUSSION: Forty-eight /51.1%/ of 94 patients with leiomyomatosis admitted in the clinic had been experiencing CPP. CPP had been the reason for diagnosing leiomyomas. A dependency was determined between quantitative value of CPP and: localization of leiomyomas, presence of another accompanying myoma gynaecological pathology, body mass index, histological changes, time of the onset of CPP, chronological appearance according to day and menstrual cycle. Pain qualitative characteristics were mainly defined by localization of leiomyomas, histological changes in them and eventually a presence of another accompanying myoma gynaecological pathology. CONCLUSION: Building up a specific for leiomyomatosis pain profile helps to provide a faster and more accurate diagnostic assessment and therapeutic management.

[How to avoid a haemotransfusion which is not lifesaving? (our experience with administration of intravenous iron to pregnant women and young mothers)]. / Kak da izbegnem edno kruvoprelivane, koeto ne e zhivospasiavashcho? (Nashiiat opit ot prilozhenie na intravenozno zheliazo pri bremenni i rodilki).

PURPOSE: To study the effect of intravenous administration of the iron-containing medicine Venofer to pregnant women and young mothers with anaemic syndrome. MATERIAL AND METHODS: A 2-year prospective study was conducted to 50 pregnant women and young mothers, which were treated for iron deficiency anemia in First Obstetrical Clinic of University Hospital - Pleven. There were 27 pregnant women (gestational age 24-39 g. w.) and 23 young mothers. A treatment with Venofer was conducted following 5 ampules regimen of administration--1st day 3 amps and 2d day--2 amps. Venofer is a stabile iron-sucrose complex designed for intravenous application. It is a structural analogue of feritine. Control studies of haemoglobin (Hb) and erythrocytes (Er) were made on 6-7 day after the therapy. RESULTS AND COMMENT: The pregnant women had average starting Hb-data of 90.74 g/l and after the therapy--106.19 g/l. The increase was of 15.74 g/l. Young mothers had Hb-data before the therapy 88.04 g/l and after the therapy 104.5 g/l. The mean increase of Hb was of 16.46 g/l. Undesired side reactions were observed only in one pregnant woman and that necessitated the stop of therapy. Intravenous administration of iron contributed to the good, normal course of pregnancy and fetal growth, and the effect to young mothers consisted of quick and certain recovery of their general state without accomplishing haemotransfusion. CONCLUSION: Therapy with iron-containing medicine gives a good opportunity to avoid the risk of haemotransfusional infections, incopatible haemotransfusions and immunocompromizing effect of allogene haemotransfusion. It is also economically more beneficial.

[Effect of some factors on obstetrical care of women with previous cesarean section]. / Vliianie na niakoi faktori vurkhu akusherskoto povedenie pri zheni s prekarano tsezarevo sechenie.

Considering obstetrical management we should have always in mind advantages and disadvantages of vaginal birth after cesarean (VBAC) and elective cesarean section after a previous one, financial part of the elected mode of delivery in the particular case, psychological aspect of the matter (especially after an unsuccessful trial of labour--TOL) and not on the last position-patient's right to choose the way how to deliver. We performed an inquiry of 3-year-period and 50 women with a prior cesarean section, by which we studied the factors contributed in different extent to the choice of the following approach to delivery: patient's preliminary choice, the impact of medical staff during pregnancy and when entering the Department of Obstetrics, the impact of non-medical persons, complications after the previous cesarean section, patient's acquaintance with complications and consequences associated with the operative mode of delivery, as well as doctor's personal attitude to the different modes of delivery. The aim of our research is to show that by careful selection (according to the established indices) of women, who have a high probability (more than 80%) to deliver their babies vaginally and offering adequate information by educational literature and including the woman in the decision making process, the patient resistance to vaginal delivery will be reduced. In this way, the growing rate of cesarean section will be decreased by increasing the number of VBAC--undoubtedly one of the most important issue in modern obstetrics.

[The impact of some factors on obstetrical management in women with previous cesarean section]. / Vliianie na niakoi faktori vurkhu akusherskoto povedenie pri zheni s prekarano tsezarevo sechenie.

Considering obstetrical management we should have always in mind advantages and disadvantages of vaginal birth after cesarean (VBAC) and elective cesarean section after a previous one, financial part of the elected mode of delivery in the particular case, psychological aspect of the matter (especially after an unsuccessful trial of labour--TOL) and not on the last position-patient's right to choose the way how to deliver. We performed an inquiry of 3-year-period and 50 women with a prior cesarean section, by which we studied the factors contributed in different extent to the choice of the following approach to delivery: patient's preliminary choice, the impact of medical staff during pregnancy and when entering the Department of Obstetrics, the impact of non-medical persons, complications after the previous cesarean section, patient's acquaintance with complications and consequences associated with the operative mode of delivery, as well as doctor's personal attitude to the different modes of delivery. The aim of our research is to show that by careful selection (according to the established indices) of women, who have a high probability (more than 80%) to deliver their babies vaginally and offering adequate information by educational literature and including the woman in the decision making process, the growing rate of cesarean section will be decreased by increasing the number of VBAC--undoubtedly one of the most important issue in modern obstetrics.