Cervical cerclage - history and contemporary use.

OBJECTIVE: Contemporary role of cerclage as a preterm birth treatment. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital in Prague. METHODS: Research of existing literature, predominantly foreign journal articles, but also Czech literature and personal experience with the method. RESULTS: Cerclage is one of the well-known surgical procedures carried out during pregnancy. Its aim is to provide a mechanical support to the cervical canal and to keep the cervix closed. The cervical mucous plug serves as a mechanical barrier between the vagina and the uterine cavity, but it also contains many immune components which protect the fetal compartment from ascendent infections. Application of a cervical stitch can help to retain the mucous plug and thus increases the immunity of the cervical canal. Results of 15 randomised studies (Cochraine Database of Systematic R) suggest that in women with increased risk of preterm birth, cerclage decreases the occurrence of preterm birth relative to the expectant management. CONCLUSIONS: Despite the decreasing numbers of cerclage surgeries, it is still a useful method of preterm birth prevention for a specific group of women. More recently, a progesterone treatment has gained popularity. Its application, however, must begin before the 16th week of pregnancy.

A method for determination of one hundred endogenous steroids in human serum by gas chromatography-tandem mass spectrometry.

Steroid profiling helps various pathologies to be rapidly diagnosed. Results from analyses investigating steroidogenic pathways may be used as a tool for uncovering pathology causations and proposals of new therapeutic approaches. The purpose of this study was to address still underutilized application of the advanced GC-MS/MS platform for the multicomponent quantification of endogenous steroids. We developed and validated a GC-MS/MS method for the quantification of 58 unconjugated steroids and 42 polar conjugates of steroids (after hydrolysis) in human blood. The present method was validated not only for blood of men and non-pregnant women but also for blood of pregnant women and for mixed umbilical cord blood. The spectrum of analytes includes common hormones operating via nuclear receptors as well as other bioactive substances like immunomodulatory and neuroactive steroids. Our present results are comparable with those from our previously published GC-MS method as well as the results of others. The present method was extended for corticoids and 17alpha-hydroxylated 5alpha/ß-reduced pregnanes, which are useful for the investigation of alternative "backdoor" pathway. When comparing the analytical characteristics of the present and previous method, the first exhibit by far higher selectivity, and generally higher sensitivity and better precision particularly for 17alpha-hydroxysteroids.

May circulating steroids reveal a predisposition to intrahepatic cholestasis of pregnancy in non-pregnant women?

Intrahepatic cholestasis of pregnancy (ICP) is a frequent liver disorder, mostly occurring in the third trimester. ICP is not harmful to the mothers but threatens the fetus. The authors evaluated steroid alterations in maternal and mixed umbilical blood to elucidate their role in the ICP development. Ten women with ICP were included in the study. Steroids in the maternal blood were measured by Gas Chromatography-Mass Spectrometry (GC-MS) (n=58) and RIA (n=5) at the diagnosis of ICP, labor, day 5 postpartum, week 3 postpartum and week 6 postpartum. The results were evaluated by ANOVA consisting of the subject factor, between subject factors ICP, gestational age at the diagnosis of ICP and gestational age at labor, within-subject factor Stage and ICP × Stage interaction. The 17 controls were firstly examined in the week 36 of gestation. ICP patients showed reduced CYP17A1 activity in the C17,20 lyase step thus shifting the balance between the toxic conjugated pregnanediols and harmless sulfated 5alpha/beta-reduced-17-oxo C19 steroids. Hence, more toxic metabolites originating in maternal liver from the placental pregnanes may penetrate backward to the fetal circulation. As these alterations persist in puerperium, the circulating steroids could be potentially used for predicting the predisposition to ICP even before next pregnancy.

[Acute or expectant management in premature labour with preterm premature rupture of the membranes?]. / Akutní, nebo expektacní prístup u predcasného porodu s predcasne odteklou plodovou vodou?

OBJECTIVE: To evaluate current knowledge about the management of preterm premature rupture of the membranes (PPROM). DESIGN: Review article. SETTING: Perinatological center, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical School of Charles University, Prague. METHODS AND RESULTS: Expectant management in case of PPROM increases the incidence of infection/ inflammation but does not statistically increase mortality and serious morbidity of the infants. The incidence of infants morbidity corresponds with gestational age. The most serious complications occur in the lower gestational age. It is necessary to take an individual approach. The acute management increases the number of operative deliveries and respiratory distress syndrome (RDS) in the infants. The combination of RDS, extremely prematurity and hypoxia during the labour decreases the infants survival rate. CONCLUSIONS: The prolongation of the latency period in pregnancies above 28th week does not deteriorate the neonatal mortality or morbidity.

[Atypical pain in the uterine rupture]. / Netypická bolest pri rupture delozní

OBJECTIVE: To give attention to the rare complication of pregnancy. DESIGN: Case report. SETTINGS: Dept. of Obstetric and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital Prague. METHODS: Description of acute abdominal pain which imitated the appendicitis in case of the uterine rupture. CONCLUSION: The uterine rupture is the rare and very dangerous complication of pregnancy. In the time of increasing number of the cesarean section and the operation on the uterine wall, we must thing on the uterine rupture.

[Peripartal life-threatening hemorrhage - interdisciplinary consensus opinion]. / Peripartální zivot ohrozující krvácení - mezioborové konsenzuální stanovisko.

22 experts from the fields of gynecology and obstetrics, anesthesiology and resuscitation, intensive care, hematology and transfusion medicine has developed recommendations for diagnosis and procedure for life-threatening peripartum haemorrhage, which is still one of the most common causes of maternal mortality in childbirth. This guidelines, which is valid for the Czech Republic, supported by a total of 10 professional medical societies. There are based on new knowledge applicable at this time and is focused mainly on eliminating the most common causes of bleeding during delivery and prevention of haemorrhagic shock.

Some aspects of perinatal and maternal mortality in Albania.

OBJECTIVE: Evaluation of antenatal care, perinatal mortality, neonatal mortality, maternal mortality, number of births, the incidence of low birth weight infants in Albania. DESIGN OF THE STUDY: Retrospective study. SETTING: Queen Geraldine University Hospital of Tirana, Albania. METHODS: The population of this country is estimated to be approximately 3,2 million and comprises very young people. Twenty five percent of the population is under 15 years of age and 46% is under 25 years [2]. The fertility rate in 2009 was 1.6 children per woman of childbearing age. The urban population accounts for 45% and the rural population for the remaining 55% of the total population [2]. The health care system is spread across nearly the entire territory and is classified as primary (villages and small towns), secondary (several cities) and tertiary (in the capital, University Hospital). Primary health care is provided at 2327 health care units. The chief activity of the family doctors and general practitioners working in such units are focused on providing health care for mother and children. Ten percent of the annual births are delivered at the Maternity Hospital of Tirana (tertiary care) which has 300 beds and another 40 beds particularly for premature infants. More than 50% of the high risk pregnancies from other districts are referred to the Maternity Hospital of Tirana. RESULTS: The annual live births in Albania was in (2010) 33,856. The total perinatal mortality rate is 10,9 per 1000 live births. The total neonatal mortality rate in 2010 was 9.7 per 1000 live births. The early postnatal mortality rate was 6.1 per 1000 births. Number of maternal deaths for 100, 000 live births was 6.0 in 2010.

Pregnancy-associated plasma protein A polymorphisms in patients with risk pregnancies.

Pregnant women are often threatened by hypertension, symptoms of preterm labour, hepatopathy, and other. These complications might be the consequence of genetic factors together with involvement of environmental factors. We were searching for three polymorphisms Arg654Lys, Ala678Pro and Thr686Ala in exon 5, and two polymorphisms Phe802Leu, Ser827Ser/Leu in exon 7, and for the new mutations in exons 5 and 7 of the pregnancy-associated plasma protein A gene in the studied group consisting of 203 women - 79 pregnant women in time of preterm labour, 24 pregnant women suffering from preeclampsia, and 100 healthy pregnant and non-pregnant women serving as controls. We did not find any divergence from wild-type form of these polymorphisms in any of the studied groups, which led us to the hypothesis that these polymorphisms are not associated with our studied group of Caucasian origin. However, further studies with a larger group of subjects are needed to confirm our results.

[Progesterone neuroactive metabolites in human pregnancy]. / Progesteron a jeho neuroaktivní metabolity v mechanismu porodu.

OBJECTIVE: Review of the physiological role of neuroactive and neuroprotective steroids in human pregnancy. DESIGN: A review article. SETTING: Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and General Hospital, Prague. CONCLUSION: Human parturition is a multi-factorial process. Various mechanisms related to the onset of labor were suggested. Estrogens show accelerating increase in late pregnancy, which probably reflect the increasing activity of fetal zone of the fetal adrenal. This zone is stimulated by progressive increase of placental CRH resulting in excessive production of conjugated 3beta-hydroxy-5-en-steroids, which are transported by circulation to placenta and further metabolized to active hormones. Some progesterone metabolites probably participate in pregnancy sustaining via modulation of ligand-gated ion channels in the CNS and periphery. In this review, the question was addressed whether the catabolism of pregnancy sustaining progesterone metabolites accelerate like the estrogen formation.

Pathophysiology of preterm labour.

A specific pathogenic process of premature delivery represents the inflammation. Birth canal infections seem to play a key role in the ethiopathogenesis of premature delivery; the related biochemical changes significantly affect perinatal morbidity and mortality. Other potential causes, particularly hormone metabolism disorders or uteroplacental ischaemia have been intensively studied. This process is related both to the mother and fetus. Fetal inflammatory response (FIRS)--can occur without maternal response--and it is related to a significant increase in perinatal morbidity. FIRS has definite laboratory, histological and clinical criteria. Effective primary prevention of premature delivery does not exist at present. The sensitivity and specificity of so far used laboratory markers is low. Thus, the research is focused on finding new inflammation markers allowing the early identification of pregnant women at a high risk of premature delivery and fetal inflammation. The screening of women at a high risk by means of new laboratory and ultrasound tests belongs to the most important steps in secondary and tertiary prevention of premature delivery. Intensive research of potential trigger mechanisms has been carried out, including a variety of gene types, which are potentially related to the process of premature delivery.

[News in pathophysiology and management of preterm labour]. / Novinky v patofyziologii a managementu predcasného porodu.

OBJECTIVE: To summarize available data concerning pathophysiology and management of preterm labour and their use in clinical practice. SETTING: Department of Obstetrics and Gynecology od the First Faculty of Medicine, Charles University, and General Teaching Hospital, Prague. DESIGN: Review article. METHODS: Compilation od published data from scientific literature. CONCLUSION: Birth canal infections seem to play a key role in the ethiopathogenesis of premature delivery; the related biochemical changes significantly affect perinatal morbidity and mortality. Other potential causes, particularly hormone metabolism disorders or uteroplacental ischaemia have been intensively studied. The particular pathogenetic process of premature delivery is inflammation. This process is related to both mother and fetus. Fetal inflammatory response (FIRS)--can occur without maternal response--is connected with significant increase in perinatal morbidity. FIRS is characterised by defined laboratory, histological and clinical criteria. Effective primary prevention of premature delivery does not exist at present. The sensitivity and specificity of the laboratory markers having been used so far is low. Thus, the research is focused on finding new inflammation markers to allow early identification of pregnant women at a high risk of premature delivery and fetal inflammation. The screening of women at a high risk by means of new laboratory and ultrasound tests belongs to the most important steps in secondary and tertiary prevention of premature delivery. Intensive research of potential trigger mechanisms has been carried out, including a variety of gene types, which are potentially related to the process of premature delivery. We try to exercise new informations about pathophysiology of preterm labour in prenatal care, firstly about thrombophillias and gestagens. We also use a principles of "evidence based medicine" and revalue importance of steroids, tocolytics and antibiotics.

[Spontaneous symphysis pubis rupture followed by intraabdominal bleeding during the vaginal delivery]. / Spontánní ruptura symfýzy následovaná profúzním krvácením do dutiny brianí behem vaginálního porodu.

Symphysis pubis rupture is rare but life-threatening complication of vaginal delivery. Prompt diagnosis and therapy of this complication is crucial. We present a case report of a patient with a symphysis pubis rupture followed by severe intraabdominal bleeding. The therapy of symphysis pubis rupture is usually conservative according to the available sources. In the case of our patient osteosynthesis was performed with an excellent result.

Prenatal and perinatal management of preterm labour.

New knowledge of the pathophysiology of premature birth enables us to introduce new approaches in prenatal care as well as the management of premature delivery. These apply for the patients with subclinical risk factors, particularly with thrombophilias, chronic infections or other latent chronic infections. The peri- and pre-conceptional dispensarisation of these women might help reduce the development of premature delivery. Secondary prevention with the administration of gestagens is highly important for women with anamnestic or existing risk of premature delivery. During the underlying premature delivery, it is advisable to re-evaluate the significance of the administration of antibiotics and tocolytics as well as timing of corticoid dosage in the induction of foetal lung maturity. Using new diagnostic and therapeutic methods, the aim of present premature delivery management is to prolong the duration of pregnancy to the maximum with the lowest risk of the development of foetal inflammatory response possible and, therefore, with a low risk of long-term handicaps in children.

[2200 g-weight-fibroid: abdominal mymectomy in the twentieth week of pregnancy]. / Abdominální myomektomie 2200 g vázícího myomu ve 20. týdnu gravidity.

OBJECTIVE: To present our clinical experience with a case of myomectomy of very big myoma during the second trimestr of pregnancy and to analyse current articles with this topics. Two myomectomies in one pregnancy (in the second trimestr and during the cesarian section) are presented. DESIGN: Review article, case report. RESULTS: A case report of 36-years-old nulliparous woman with 2 big fibroids in pregnancy is presented. The pregnancy was troubleless until 20th week, than she was hospitalized with suddenly appeared pain in epigastrium. A big necrotisis of fibroid was found during the examination. The clinical situation of the pacient rapidly deteriorated - in 24 hours the pain increased and ileus appeared. The operation due to vital indication was carried out with maximal effort to preserve the pregnancy. The 2200g-weigh-myoma was removed abdominally and the pregnancy continued without another complication. The cesarian section was done in 38-week-old pregnancy and a healthy child was delivered. The second big fibroid on the back of the uterus was found during the cesarian section, myomectomy and large adhesiolysis was done. The pacient was hospitalized during the puerperium again with reapperance of ileus. The therapy of ileus was conservative. A case report presents a rare ocurence of big myomectomy during the second trimestr of pregnancy which was complicated by recidivans ileus due to large adhesive process in abdominal cavity. CONCLUSION: The prevalence of fibroids in pregnancy is between 2 and 4%, only 10 procents of this pregnancies are complicated, the necrosis of fibroid during the pregnancy is one of the most difficult cases.

[Intrapartal fetal monitoring, sensitivity and specificity of methods]. / Intrapartální fetální monitoring, senzitivita a specificita metod.

OBJECTIVE: To evaluated sensitivity and specificity of presently used methods for intrapartal monitoring (CTG, FpO2 a STAN S-21) and their mutual comparison. TYPE OF STUDY: A prospective study. SETTING: Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and general Teaching Hospital, Prague. METHOD: In 114 pregnant women with high-risk or pathological course of pregnancy the authors evaluated the capability of individual methods to predict intrapartal hypoxia, determined on the basis of postnatal evaluation of parameters observed (Apgar score in 1st minute, pH from umbilical artery, lactate levels in fetal blood, base excess (BE) and postpartum condition of fetus evaluated by a neonatologist). Each method was categorized according to its importance. The quality of individual methods was evaluated by means of their sensitivity and specificity as well as by the area under ROC (Receiver Operating Characteristic), i.e. AUC (Area under Curve). A similar or different prediction of the condition of the newborn by these individual methods was evaluated by the McNamara test of symmetry. In 50 deliveries performed by Cesarean section and 24 forceps deliveries the authors evaluated postnatal pH from umbilical artery and evaluation by Chi-square test. The women in childbed were infused with a tocolytic drug (hexoprenalin) before Cesarean section. All tests were performed at 5% level of significance. RESULTS: Low level of Apgar score in the 1st minute and less) always indicated CTG, but also a large proportion of normal newborns. STAN, in contrast, well indicates all newborns with a normal point evaluation. The best balanced evaluation of the newborns is provided by FpO2 and there was a significant difference between CTG and FpO2. In evaluating pH from the umbilical artery (pH < 7.20), TCG proved to be most sensitive again but displayed low specificity. STAN was the best predictor of newborns with normal pH. In evaluating high levels of lactate (> 3.7mmol/L) and BE (> -10) and related demonstration of metabolic acidosis STAN proved to be the best predictor. The condition of the newborn evaluated by a neonatologist immediately after birth (medium or heavy depression) was best predicted by FpO2. In deliveries performed by Cesarean section and after the administration of tocolysis the postnatal pH was higher then in forceps deliveries without acute tocolysis. The occurrence of emergencies in the course of a pathological delivery in individual methods is as follows: CTG, FpO2 and STAN. CONCLUSION: Even though CTG displays a very low specificity, this method should not be rejected, since it draws attention of the obstetrician very early to the possibility of developing hypoxia. FpO2 or STAN gives more precision to the situation and demarcates a correct moment for ending the delivery for the indication of fetus hypoxia intra partum. STAN is the best predictor for conditions of developing metabolic acidosis, evaluated postnatally by the level of lactate and BE in fetal blood.

[Diagnosis and management of infection and its role in preterm labor]. / Diagnostika a management infekce u predcasného porodu.

OBJECTIVE: Analysis of contemporary knowledge of infection and its role in etiology and pathogenesis of preterm labor. DESIGN: Review article. SETTING: Department of Gynecology and Obstetrics, 1st Faculty of Medicine, Charles University, Prague. METHODS: An overview of published data. CONCLUSION: Infection is considered the most significant cause of preterm labor. The current research tend towards searching for local cervicovaginal markers of infection. An important role in the prenatal care is played by cervical ultrasonography which together with cervicovaginal markers can sort out the group of women with high risk of the preterm labor. Cervicovaginal markers can reveal microbial invasion into higher parts of the birth canals during the intrapartal care and justify the administration of antibiotics especially to women with the premature rupture of membranes. The routine administration of antibiotics was reevaluated in the management of preterm labor. The question of optimal antibiotics remains open.

[Vaginal infections screening in pregnancy]. / Skrínink vaginálních infekcí v tehotenství.

Preterm birth before the 37th gestational week is most frequently caused by infection. The agents are aerobic and anaerobic bacteria. Infection usually ascends from the vagina. Microorganisms entering the choriodecidual space induce pro-inflammatory cytokines, which trigger prostaglandin synthesis and contraction activity of the uterus. Cytokines can also release proteases, which cause premature outflow of the amnionic fluid. Screening of vaginal infections is indicated in all cases of imminent preterm parturition and in the group of risk pregnancies. Screening on Streptococcus B is indicated to all pregnant women in the gravidity weeks 35 to 37. Beside streptococcus infections with the risk of disease of the neonate being 2 to 3 per 1000 of vital newborns, bacterial vaginosis caused by Gardnerela vaginalis is frequently diagnosed. Effective treatment of symptomatic cases of the advanced pregnancy is five days long administration of Metronidazol or Clindamycin--vaginal crème. Another frequent cause of the preterm birth is chlamydial infection. The best contemporary treatment is Azitromycine for five days. Therapy of women without symptoms of the imminent preterm parturition does not decrease its occurrence. It is therefore not recommended as well as is not recommended the therapy of pregnant women with asymptomatic bacterinuria. Beside the classical cultivations, detection of antibodies, DNA analysis and serum infection markers (leucocytes, C-reactive protein), detection of pro- inflammatory cytokines in the serum and in the vaginal secret (IL-6, IL-8, TNFalpha etc.) are used to diagnose vaginal infections.

[Pregnancy and labor after combined pancreas-kidney transplantation in Czech Republic]. / Tehotenství a porod po kombinované transplantaci ledviny a pankreatu v Ceské republice.

OBJECTIVE: To inform about the first own experiences and to present opinion on leading pregnancy and delivery after a combined pancreas and kidney transplantation. DESIGN: Case report and review article. SETTING: Department of Obstetric and Gynecology, 1st Medical Faculty of the Charles University and General Faculty Hospital, Prague. RESULTS AND CONCLUSIONS: Pregnancies and deliveries after the transplantation of solid organs are not common. Mostly there are experiences with women after kidney transplantation, smaller or no experiences are with women after transplantation of other solid organs. About 25 pancreas transplantation per year are performed in the Czech republic. Two women after the combined kidney and pancreas transplantation were the first in Czech republic to get pregnant spontaneously and delivered by using a chronic immunosupressive. therapy (Prograf, Imuran, Prednison) in 2002 and 2003. These single pregnancies were led as a high-risk pregnancy in Regional Perinatology Center in collaboration with Transplant and Diabetic Center. Both pregnancies were termined from the obstetrical indication before the term by cesarean section. Both children were healthy. The pregnancy of both patients has not affected the function of the transplanted organs and development of both children has been normal.

[Threatening uterine rupture in pregnancy after previous laparoscopic myoma enucleation. Case report]. / Hrozící delozní ruptura v gravidite po predchozí laparoskopické enukleaci myomu. Kazuistika.

OBJECTIVE: To evaluate the negative effect of uterine myoma enucleation forcompact structure of the uterus. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, Pronatal Sanatoruim, Prague METHODS: In this study, the authors analyze their experience of the course of pregnancy in a patient who had uterine myoma enucleation with penetration to the uterine cavity and large coagulation. The pregnancy was terminated by caesarean section for the indication of prior uterine surgery and the risk of uterine rupture in 38 week of pregnancy. CONCLUSION: This case report demonstrates the risk of uterine rupture in pregnancy after laparoscopy myoma enucleation.

[Foetal ECG in the prediction of intrapartum hypoxia]. / Fetální EKG v predikci intrapartální hypoxie plodu.

Intrapartum foetal hypoxia represents one of the most frequent causes of the hypoxia-ischemia CNS injury in newborns and it can result in the development of a permanent handicap. It often results from the underestimation of the development of the delivery by the obstetrician who conducts delivery and who is responsible for it. That is why the contemporary obstetrics is using new instruments, enabling to evaluate objectively the development of the intrapartum foetal hypoxia. The praxis consequently introduced cardiotocography (CTG), foetal pulse oximetry (FpO2) and recently new methods for evaluation of ST interval in foetal ECG- STAN. The last method has the highest specificity for prediction of the foetal hypoxia and it properly signalises the development of the metabolic foetal acidosis, which threatens the foetus during delivery and which can impair the vital organs. Foetal myocardium sensitively responds to the release of stress hormones, to the development of anaerobic metabolism and to the increase of potassium levels. The development of hypoxia manifests in ECG as a subsequent rise of T wave, elevation of T/QRS segment and as a significantly biphasic ST interval. The last sign indicates serious state of the foetus in utero accompanied with metabolic acidosis.