[Laparoscopic abdominal cerclage in a patient with recurrent miscarriages abortions - case report]. / Laparoskopická abdominální cerkláz u pacientky s habituálním potrácením - kazuistika.

OBJECTIVE: The use of laparoscopic abdominal cerclage in a patient with habitual miscarriage. DESIGN: Case report and literature review. SETTING: Department of Obstetrics and Gynecology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Department of Neonatology, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc, Institute of Medical Genetics, University Hospital Olomouc, Faculty of Medicine, Palacký University Olomouc. CASE REPORT: The patient is a 37 years old woman with a history of recurrent miscarriages. She had one labor at term and six pregnancies that were lost in the second trimester despite McDonald cerclages. Abdominal cerclages are necessary when the standard transvaginal cerclages fail or anatomical abnormalities preclude the vaginal placement. The disadvantage of the transabdominal approach is that it requires at least 2 laparotomies with significant morbidity and hospital stays. We discuss a case of abdominal cerclage performed laparoscopically. A 5 mm Mersilene tape was placed laparoscopically at the level of the internal os as an interval procedure. We feel it offers less morbidity and in the proper hands eliminates or significantly shortens hospital stays. Subsequent pregnancy was terminated at 28 weeks by caesarean section after premature rupture of membranes. CONCLUSION: Laparoscopic abdominal cerclage seems to be relatively effective option for the prevention of habitual abortion patients, which fail conventional surgical procedures in dealing with cervical incompetence. The success of subsequent full term pregnancy is given as 70%.

[Robotic sacrocolpopexy - two case reports and literature overview]. / Robotická sakrokolpopexe - dve kazuistiky a literární prehled.

OBJECTIVE: To describe first two cases of robotic sacrocolpopexy in the Czech Republic. DESIGN: Two case reports with literature overview. SETTING: Department of Obstetrics and Gynaecology, Faculty of Medicine and Dentistry, Palacky University in Olomouc. CASE REPORT: Robotic sacrocolpopexy was performed in two patients of the age 36 and 59 at the department of obstetrics and gynecology in Olomouc in 2009. We describe vaginal prolapse treatment in one case, and supracervical hysterectomy with cervicosacropexy in the other. These two cases are compared with literature overview, including long-term follow-up. CONCLUSION: Robotic sacrocolpopexy encompasses all advantages of minimally invasive surgery. Our results, as well as published data show very good long term results of vaginal prolapse treatment using this approach.

[Spontaneous antepartal RhD alloimmunization]. / Spontánní antepartální RhD aloimunizace.

AIM OF THE STUDY: Assess the incidence of spontaneous antepartal RhD alloimmunization in RhD negative pregnant women with an RhD positive fetus. DESIGN: Clinical study. SETTING: Department of Obstetrics and Gynecology, Medical School and University Hospital Olomouc. METHODS: A total of 906 RhD negative women with an RhD positive fetus and without the presence of anti-Dalloantibodies at the beginning of pregnancy were examined. Always it was a singleton pregnancy, RhD blood group of the pregnant women was assessed in the 1st trimester of pregnancy, RhD status of the fetus was determined after delivery. Screening for irregular antierythrocyte antibodies was performed in all women in the 1st trimester of pregnancy, at 28-32 weeks gestation and immediately prior to delivery at 38-42 weeks gestation. Screening for irregular antierythrocyte antibodies was performed also at 6 months following delivery in all cases of positive antibodies before delivery. Antibody screening was performed using the indirect antiglobulin (LISS/NAT) and enzyme (papain) test with their subsequent identification using a panel of reference erythrocytes by column agglutination method Dia-Med. After delivery, the volume of fetomaternal hemorrhage was assesed in all RhD negative women and RhD alloimmunization prophylaxis was performed by administering the necessary IgG anti-D dose; none of the women were administered IgG anti-D antepartally. RESULTS: During screening for irregular antierythrocyte antibodies at 28-32 weeks gestation, anti-D alloantibodies were diagnosed in 0.2% of the women (2/906); immediately prior to the delivery at 38-42 weeks gestation, anti-D alloantibodies were diagnosed in 2.3% of the women (21/906) and repeatedly even at 6 months following delivery (21/157). In 82.7% of the women (749/906), examination at 6 months following delivery was not performed, therefore in these women spontaneous antepartal RhD alloimmunization cannot reliably be ruled out. Alloimmunization may not be diagnosed yet at term of delivery. If anti-D alloantibodies were not present prior to the delivery, these women were all administered IgG anti-D in a dose of at least 125 µg after delivery. CONCLUSION: In RhD negative women with an RhD positive fetus, the incidence of spontaneous antepartal RhD alloimmunization was at least 2.3%. Most cases may theoretically be prevented by prophylactic administration of 250 µg of IgG anti-D to all RhD negative women at 28 weeks gestation.

[RHD genotyping from cell-free fetal DNA circulating in pregnant women peripheral blood and sensitivity assessment of innovated diagnostic approaches for introduction into the clinical practice]. / Stanovení RHD genotypu plodu z plazmy periferní krve tehotné zeny a posouzení citlivosti nových diagnostických postupu pro zavedení do klinické praxe.

OBJECTIVE: Introduction of fetal RHD genotyping from cell-free fetal DNA circulating in the peripheral blood of pregnant women to clinical practice. Sensitivity assessment of innovated method using range of dilution series and internal control of amplification. DESIGN: Procedure creating of noninvasive determination of fetal RHD genotyping from blood plasma of pregnant women. Detection of limit of minority representation RHD+/- sample in the RHD-/- sample. SETTING: University Hospital Olomouc, Institute of Medical Genetics and Fetal Medicine, Clinic of Obstetrics and Gynecology, Transfusion Department. METHODS: TaqMan Real-Time PCR without an internal amplification controls. Optimization and calibration of RHD genotyping using RHD multiplex by TaqMan Real-Time PCR with an internal amplification control and by minisequencing (Snapshot - multiplex) with an internal amplification controls. RESULTS: RHD positive or negative fetuses were determined by amplification curves from Real-Time PCR system that matches the parameters for the evaluation of the output data using series of amplification and contamination parallel controls. TaqMan based Real-Time PCR and minisequencing (SNaPshot) based quantification were able to detect 0.22% of artificial RHD+/- sample diluted in RHD-/- sample. In addition, SNaPshot assay is suitable for heterozygozity and homozygozity recognition. CONCLUSION: Current established and routinely used procedure is based on the detection of exon 7 of the RHD gene and on the series of parallel amplification and contamination controls. Both newly developed methods could be, after validation of the larger set of control samples, introduced into clinical practice.

[Incidence of erythrocyte alloimmunization in pregnant women in olomouc region]. / Incidence erytrocytární aloimunizace u tehotných zen v olomouckém regionu.

OBJECTIVE: To determine the incidence of clinically significant anti-erythrocyte alloantibodies in pregnant women, which can cause severe hemolytic disease in the fetus and newborn. DESIGN: Retrospective-prospecitive clinical study. SETTING: Transfusion Department, University Hospital Olomouc, Department of Obstetrics and Gynecology, University Hospital Olomouc. SUBJECT AND METHOD: Between the years 2000-2011, a total of 45 435 pregnant women were examined at the Department of Transfusion Medicine at the University Hospital Olomouc. Screening for irregular anti-erythrocyte antibodies followed by identification of the alloantibody was performed in all women at the beginning of the pregnancy. RESULTS: Clinically significant anti-erythrocyte antibodies were diagnosed in 1.5% pregnant women (683/45435). The most common cause of maternal alloimmunization was antigen E with an incidence of 5.7 (258/45435), followed by antigen D 4.0 (181/45435), M 1.5 (70/45435), C 1.2 (54/45435), K 1.2 (55/45435), c 0.6 (26/45435), S 0.4 (20/45435), Jka 0.2 (9/45435), PP1pk (Tja) 0.1 (3/45435) and antigen Fya 0.0 (2/45435). CONCLUSION: Despite performing prophylaxis for RhD alloimmunization by administering anti-D immunoglobulin to RhD negative women during pregnancy and after the birth of an RhD positive child, antigen RhD still represents the 2nd most frequent cause of maternal erythrocyte alloimmunization. The remaining clinically significant alloimmunizations are caused by non-D antigens of the Rh system, antigens of the Kell system, and rarely observed antigens of the MNS and Kidd blood systems.

[Epidemiology and management of thyroid disorders in pregnancy]. / Epidemiologie a management poruch stítné zlázy v tehotenství

OBJECTIVE: Determine the incidence of asymptomatic decrease of thyroid function at pregnant women in the first trimester of pregnancy in the Olomouc region. MATERIAL AND METHODS: The authors examined 461 women in the first trimester of pregnancy. There was measured serum concentrations of thyrotropin (TSH), free thyroxine (FT4) and thyroidperoxidaseantibody (TPOAb). RESULTS: TSH concentration > 2.5 mIU/l was in 21% women (96/461). Reduction of FT4 < 9.8 pmol/l was found in 15 of the 96 women screened with a TSH greater than 2.5 mU/l. For women with TSH 2.5 mU/l, however, was found reduction of the FT4 < 9.8 pmol/l in 11 cases. TSH concentration > 3 mIU/l was found in 14% women (64/461). Reduction of FT4 < 9.8 pmol/l was found in 13 of the 64 women screened with a TSH greater than 3 mU/l. TSH concentration> 3.5 mIU/l in 10% of women (45/461). Reduction of FT4 <9.8 pmol/l was found in 11 of 45 examined women with TSH greater than 3.5 mU/l. TSH concentration > 4 mIU/l in 8% of women (35/461). Reduction of FT4 < 9.8 pmol/l was found in 10 of35 examined women with TSH greater than 4 mU/l. TPOAb was raised over 20 kU/l in 17% of women (78/461). CONCLUSIONS: Asymptomatic decrease of thyroid function was during direct examination in the first trimester of pregnancy diagnosed at more than 8% of pregnant women. Untreated decreased of thyroid function at mothers may have a negative impact on the course of pregnancy, as well as on fetal development, especially in the psychomotoric area. The presence of TPOAb indicate an increased risk of developing thyroid fictional disorders in pregnancy or postpartum thyroiditis. TSH in pregnancy may be affected by elevated levels of hCG and may slightly decrease because hCG and TSH have a common alpha subunit. Discussed the specific standards for TSH in pregnant and implementation of systematic screening for women in early pregnancy or before planned conception. Perspective, however, we see in tests of thyroid function already in preconception period.

[Erythrocyte alloimmunization in pregnant women, clinical importance and laboratory diagnostics]. / Erytrocytární aloimunizace tehotných zen, klinický význam a laboratorní diagnostika.

OBJECTIVE: The aim of this review is to give comprehensive summary of erythrocyte alloimunization of pregnant women, laboratory dignostics and clinical importance. DESIGN: Review. SETTING: University Hospital Olomouc, Transfusion Department, Department of Obstetrics and Gynecology. SUBJECT AND METHOD: Based on literature analysis using database search engines PubMed, Google Scholar, Ovid in field of erythrocyte antibodies, laboratory diagnostics and clinical importance up-to-date knowledge. CONCLUSION: Erythrocyte alloimunization anti-D antibodies decreases in connection with the introduction of immunoprofylaxis. Immunization of non RhD antibodies with impossibility using of immunoprofylaxis remains still clinical problem.

[Disorders of the thyroid gland in pregnancy]. / Poruchy funkce stítné zlázy v tehotenství

Functional disorder of the thyroid gland affects individuals of all ages. Incidence and nature of the disease is influenced by supplying iodine, genetic and immunological factors and other external effects. Increased function occurs in 1-2% of the adult population, reduced function in the younger population diagnosed in about 5%, in women aged over 50 years we have been at 10-15%. The incidence of thyroid diseases is higher in women than in men (5-8:1) and significantly increases with age. Approximately as common as overt forms of thyroid disease are their subclinical forms. Thyroid disease, especially asymptomatic reduction of function for direct examination is diagnosed up to 5% of pregnant women. Untreated decreased thyroid function of mothers may have significant negative impact on the course of pregnancy, as well as on fetal development, especially in the psychomotoric area. Women with the presence of antithyroid antibodies are at risk of pregnancy deepening malfunctions and/or postpartum thyroiditis. Czech Endocrinological Society currently pursuing a systematic screening of other risk population groups, including notably the pregnant and nursing women, women in old age and ill with some other disease or treatment with certain drugs.

[The influence of maternal age, parity, gestational age and birth weight on fetomaternal haemorrhage during spontaneous delivery]. / Vliv veku rodicky, parity, délky trvání tehotenství a hmotnosti plodu na fetomaternální hemoragii pri spontánním porodu.

OBJECTIVE: Determine the influence of maternal age, parity, gestational age and birth weight on the volume of fetal erythrocytes which enter the maternal circulation during spontaneous delivery. Determining these parameters would enable improving the guidelines for RhD alloimmunization prophylaxis. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and Gynecology, University Hospital, Olomouc. METHODS: A total of 2413 examinations were performed. The amount of fetal erythrocytes entering maternal circulation during uncomplicated spontaneous delivery of one fetus was determined by flow cytometry using the BDFACSCanto cytometer (Becton Dickonson International). Laboratory processing: Fetal Cell Count kit (Diagnosis of Feto-maternal transfusion by flow cytometry), IQ Products, IQP-379. Calculation of total volume of fetal erythrocytes entering maternal circulation: Scientific Subcommittee of the Australian and New Zealand Society of Blood Transfusion. Guidelines for laboratory assessment of fetomaternal haemorrhage. 1st ed. Sydney: ANZSBT, 2002: 3-12. RESULTS: The average maternal age when FMH 1.8 ml (95 perc) was 29.4 years vs. 29.1 years when FMH > 1.8 ml, median 30 years in both groups, the difference was not statistically significant (p = 0.501). The average gestational age when FMH 1.8 ml (95 perc) was 275.3 days vs. 276.9 days when FMH > 1.8 ml, median 278 days (39 weeks +5 days) vs. 276 days (39 weeks + 3 days), the difference was not statistically significant (p = 0.849). The average birth weight when FMH 1.8 ml (95 perc) was 3312 g vs. 3353 g when FMH > 1.8 ml, median 3340 g vs. 3330 g, the difference was not statistically significant (p = 0.743). FMH > 1.8 ml (5 perc) was present in 4.1% of primiparas (42/1023), in 4.2% of secundiparas (44/1050) and in 5.3% of multiparas (18/340), the difference was not statistically significant (p = 0.607). The difference in maternal age, parity, gestational age and birth weight were also not statistically significant for fetomaternal hemorrhage FMH > 2.1 ml (2.5 perc), FMH > 2.5 ml (n = 25), FMH > 5 ml (n = 5). CONCLUSION: Maternal age, parity, gestational age and birth weight does not present a risk factor for excessive fetomaternal hemorrhage during spontaneous delivery.

[Fetomaternal haemorrhage in delivery by cesarean section]. / Fetomaternální hemoragie pri porodu císarským rezem.

OBJECTIVE: To determine the incidence and volume of fetomaternal haemorrhage (FMH) in normal vaginal delivery and in delivery by cesarean section. Determination of these parameters would enable optimalization of guidelines for RhD alloimmunization prophylaxis. DESIGN: A prospective cohort study. SETTING: Palacky University Hospital, Olomouc, Czech Republic; University Hospital, Ostrava, Czech Rebublic. METHODS: A total of 4862 examinations were performed. The volume of fetal red blood cell (RBC) entering maternal circulation in normal vaginal delivery (control group, n = 3295) and in delivery by cesarean section (risk group, n = 1567) was assessed by flow cytometry. FMH = fetal RBC volume; fetal blood volume si double (expected fetal hematocrit is 50%). RESULTS: The fetal RBC volume diagnosed in maternal circulation after delivery ranged from insignificant FMH < or = 0.1 ml to excessive FMH = 65.9 ml (median 0.7; mean 0.79; SD 1.38). High values of FMH > 1.7 ml were observed in 5.8% cases (280/4862), FMH > 2.0 ml in 3.2% (157/4862), FMH > 2.0 ml in 1.4% (69/4862) and excessive FMH > 5ml (IgG anti-D insufficient dose 100 microg) in 0.25% (15/4862). Delivery by cesarean section presented a higher risk of incidence of high values of FMH > 1.7 ml (OR 1.6; p 0.0002), FMH > 2.0 ml (OR 2.2; p <0.0001) and FMH > 2.5 ml (OR 2.2; p 0.002) when compared with normal vaginal delivery. It did not, however, present a statistically significant risk factor for the incidence of excessive FMH > 5ml. CONCLUSION: In normal vaginal delivery as well as in delivery by cesarean section, FMH less than 5 ml (10 ml of whole blood) occurs in the great majority of cases, and thus for the prevention of RhD alloimmunization, an IgG anti-D dose of 100 microg should be sufficient. Contrarily, only rarely does greater FMH occur and delivery by cesarean section does not present a risk factor.

[Possibility to identify fetomaternal haemorrhage]. / Moznosti stanovení fetomaternální hemoragie.

UNLABELLED: Fetomaternal haemorrhage (FMH) is a status characterised by penetration of fetal blood into the maternal circulation which happens mostly at delivery. FMH may cause erythrocytal alloimmunisation of woman. That is why anti-D immunoglobulin (IgG anti-D) is being administered to RhD negative women after delivery of RhD positive fetus. IgG anti-D is administered to RhD negative women standardly and in much greater quantities than is actually necessary. However, on the other hand, it is not possible to diagnose cases where a greater dose is required. To optimalise prevention of RhD alloimmunization in RhD negative women, it is important to diagnose conditions where fetomaternal haemorrhage (FMH) occurs, precisely define its volume and consequently administer the required dose of IgG anti-D. The ability to reliably detect fetomaternal haemorrhage (FMH) and precisely define its volume would allow better and less expensive prevention of RhD alloimmunization in RhD negative women. IgG anti-D could thus be administered only in cases that are actually indicated and only in doses necessary for preventing RhD alloimmunization. Accurate quantification of FMH is determined by flow cytometry. DESIGN: Review. SETTING: Department of Obstetrics and Gynecology, Department of Alergology and Clinical Immunology, University Hospital Olomouc.