The perinatal outcomes of women treated for Asherman syndrome: a propensity score-matched cohort study.

STUDY QUESTION: Do the perinatal outcomes of patients following hysteroscopic treatment for Asherman syndrome (AS) differ from that of a control population? SUMMARY ANSWER: Perinatal complications including placental issues, high blood loss, and prematurity in women after treatment for AS should be considered as moderate to high risk, especially in patients who have undergone more than one hysteroscopy (HS) or repeated postpartum instrumental revisions of the uterine cavity (Dilation and Curettage; D&C). WHAT IS KNOWN ALREADY: The detrimental impact of AS on obstetrics outcomes is commonly recognized. However, prospective studies evaluating perinatal/neonatal outcomes in women with AS history are sparse, and the characteristics accounting for the respective morbidity of AS patients remain to be elucidated. STUDY DESIGN, SIZE, DURATION: We conducted a prospective cohort study utilizing data from patients who underwent HS treatment for moderate to severe AS in a single tertiary University-affiliated hospital (enrolled between 01 January 2009 and March 2021), and who consequently conceived and progressed to at least 22nd gestational week of pregnancy. Perinatal outcomes were compared to a control population without an AS history, retrospectively enrolled concomitantly at the time of delivery for each patient with AS. Maternal and neonatal morbidity was assessed as well as the characteristics-related risk factors of AS patients. PARTICIPANTS/MATERIALS, SETTING, METHODS: Our analytic cohort included a total of 198 patients, 66 prospectively enrolled patients with moderate to severe AS and 132 controls. We used multivariable logistic regression to calculate a propensity score to match 1-1 women with and without AS history based on demographic and clinical factors. After matching, 60 pairs of patients were analysed. Chi-square test was used to compare perinatal outcomes between the pairs. Spearman's correlation analysis was utilized to investigate the correlation between perinatal/neonatal morbidity and the characteristics-related factors of AS patients. The odds ratio (OR) for the associations was calculated by logistic regression. MAIN RESULTS AND THE ROLE OF CHANCE: Among the 60 propensity matched pairs, the AS group more frequently experienced overall perinatal morbidity, including abnormally invasive placenta (41.7% vs 0%; P < 0.001), retained placenta requiring manual or surgical removal (46.7% vs 6.7%; P < 0.001), and peripartum haemorrhage occurrence (31.7% vs 3.3%; P < 0.001). Premature delivery (<37 gestational weeks) was reported more frequently also for patients with AS (28.3% vs 5.0%; P < 0.001). However, no increased frequency of intra-uterine growth restriction or worsened neonatal outcomes were observed in AS group. Univariable analysis of risk factors for AS group morbidity outcomes revealed that the main factor related to abnormally invasive placenta was two or more HS procedures (OR 11.0; 95% CI: 1.33-91.23), followed by two or more D&Cs preceding AS treatment (OR 5.11; 95% CI: 1.69-15.45), and D&C performed postpartum as compared to post abortion (OR 3.0; 95% CI: 1.03-8.71). Similarly, two or more HS procedures were observed as the most important factor for retained placenta (OR 13.75; 95% CI: 1.66-114.14), followed by two or more preceding D&Cs (OR 5.16; 95% CI: 1.67-15.9). Premature birth was significantly associated with the number of preceding D&Cs (OR for two or more, 4.29; 95% CI: 1.12-14.91). LIMITATIONS, REASONS FOR CAUTION: Although the cohort of patients with AS was enrolled prospectively, a baseline imbalance was intrinsically involved in the retrospective enrolment of the control group. However, to reduce the risk of bias, confounding factors were adjusted for using propensity score matching. The limitation to the generalization of our reported results is the single institution design in which all patients were treated for AS in one tertiary medical centre. WIDER IMPLICATIONS OF THE FINDINGS: Within our search scope, our study represents one of the first and largest prospective studies of perinatal and neonatal outcomes in moderate to severe AS patients with a prospectively analysis of the risks factors of characteristics significantly influencing reported morbidities among patients with AS. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by the Charles University in Prague [UNCE 204065] and by the institutional grant of The General Faculty Hospital in Prague [00064165]. No competing interests were declared. TRIAL REGISTRATION NUMBER: N/A.

Prevention of de novo adhesion formation in patients with Asherman's syndrome.

OBJECTIVE: To summarize recent data and knowledge of secondary prevention of the recurrence of intrauterine adhesions in patients with Ashermans syndrome. METHODS: Analysis of literature evidence and clinical experience of the authors. RESULTS: Ashermans syndrome is iatrogenic disease with problematic therapy. One of the basic issues is a need for repeated surgical interventions since the recurrence of adhesions is very frequent. Secondary prevention is a crucial factor for successful therapy in these patients. The methods applied include second--look hysteroscopy, hormonal treatment and different types of barriers. To compare their efficacy is difficult and the results of meta-analysis are contradictory. CONCLUSION: There are many different possibilities of secondary prevention of the recurrence of intrauterine adhesions; unfortunately, none of them is perfect. The usage of solid or semi-solid barriers in combination with the support of endometrium regeneration with hormonal therapy seems most reasonable.

Uterine leiomyomas with bizarre nuclei: analysis of 37 cases after laparoscopic or open myomectomy.

OBJECTIVE: The aim of this study was to analyse the clinical outcome of patients with diagnosis of leiomyoma with bizarre nuclei (LBN) undergoing uterus saving surgery due to fertility preservation. DESIGN: Retrospective clinical study. SETTING: Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University, General University Hospital, Prague. METHODS: This was a retrospective clinical study of patients with LBN diagnosis after myomectomy between January 2002 and June 2017 which were searched in our database. The data were obtained from medical documentation and from correspondence with patients. RESULTS: We identified 37 patients meeting the criteria in our database. The median age of the patients was 34.0 years. 30 patients (81.1%) underwent laparoscopic procedure, 7 (18.9.%) had open myomectomy. The perioperative appearance of fibroid was found normal in 27 cases (73.0%), in the rest the appearance was described somehow abnormal. The follow-up data were obtained from 35 women; the median follow-up time was 48 months. 9 patients (25.7%) needed re-intervention for fibroids with 2 specimens (22.2%) classified as LBN again. The overall pregnancy rate was 63.6% and life birth rate was 33.3%. We did not observe any distant recurrence of the disease or malignant recurrence or death related to the diagnosis. CONCLUSION: Uterus sparing surgery for treatment of LBN seems to be safe and reasonable therapy for women wishing to preserve fertility.

[Endometriosis and quality of life]. / Endometrióza a kvalita zivota.

OBJECTIVE: This article aims to provide a comprehensive overview of the possibilities of evaluating the impact of symptoms of endometriosis on quality of life of affected women and to overview the effect of treatment modalities in improving of the quality of their life. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague. METHODS: Review of results of published studies evaluating quality of life in patients with endometriosis. CONCLUSION: Symptoms of endometriosis decrease the quality of life of affected women, which has significant impact on society. Since the extent of endometriosis does not correlate with subjective complaints, it is suitable to evaluate the quality of life of patients in addition to assessment of the extent and classification of the disease (according to internationally accepted classification). The quality of life could be measured and compared by structured interviews or by validated questionnaires. Pharmacological as well as surgical treatment significantly improve quality of life of patients with endometriosis. Routine use of validated questionnaires of quality of life in patients with endometriosis might improve the assessment of severity of the disease and evaluation of effectiveness of the treatment in the future.

[Office hysteroscopy - management and results]. / Management a výsledky ambulantní hysteroskopie.

OBJECTIVE: Sum up the knowledge about office hysteroscopy. TYPE OF STUDY: Review of literature and our own experience. SETTING: Department of Gynaecology and Obstetrics, First Faculty of Medicine, Charles University Prague and General Teaching Hospital Prague. METHODS: Data from scientific literature and 10 years of our own experience with office hysteroscopy. CONCLUSIONS: Hysteroscopy provides optical evaluation of uterine cavity. Most of the benign intrauterine organics pathologies could be managed in a outpatient setting with a vaginoscopic approach without any anaesthesia and analgesia. Using that approach we can recommend to perform endometrial target biopsy, resection of endometrial polyps up to 1.5 cm and pedunculated submucous myomas up to 1 cm as well as resection of filmy intrauterine adhesions. Method is comfortable for well managed patients and practically complication-free.

[Laparoscopic uterus sparing treatment of uterine fibroids]. / Laparoskopická konzervativní lécba delozních myomu

OBJECTIVE: To report up-to date knowledge on laparoscopic, uterine sparing treatment of uterine fibroids. STUDY DESIGN: Review. SETTING: Uterine Fibroids Center, Department of Obstetrics and Gynecology, Charles University, Prague. METHODS: Analysis of our clinical experience and available literature resources. RESULTS: The management of uterine fibroids depends on the symptoms, location, and size of fibroids and on the reproductive plans of the patient. The surgical treatment has changed from laparotomy to minimally invasive surgery. In general, laparoscopic myomectomy (LM) is considered the best option in symptomatic patients with pregnancy plans. The laparoscopic approach is associated with lower postoperative morbidity as well as lower incidence of massive postoperative adhesion formation compared to laparotomy. The limitation of laparoscopic myomectomy is the size and the number of fibroids but also the location and the accessibility for the laparoscopic suturing. Laparoscopic uterine artery occlusion (LUAO) represents one of the alternatives to LM in patients with multiple small myomas or in patients with fibroids in unfavorable location. LUAO may be advantageously used prior to LM in order to reduce peroperative blood loss or to prevent the persisting fibroids from growing. However there is no universal treatment of uterine fibroids in fertile patients and in each single patient the indication and surgical method should be thoroughly considered. .

[Laparoscopic lymph-node dissection in gynecological surgery]. / Laparoskopická lymfadenektomie v gynekologické operative

OBJECTIVE: To analyze our experience with transperitoneal laparoscopic dissection of lymphatic nodes in women with gynecologic malignancies. STUDY DESIGN: Retrospective clinical study. SETTING: Center of gynecologic endoscopy and minimally invasive surgery; Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty in Prague. METHODS: Analysis of data from our laparoscopic procedures in the years 2006-2011. The following procedures have been included: systematic pelvic lymphadenectomy (PLN), paraaortic lymphadenectomy (PALN), pelvic sentinel node excision, focused dissection of bulky lymphatic nodes from pelvis or paraaortic area. RESULTS: We performed 177 primarily laparoscopic procedures pointed at dissection of pelvic and/or paraaortic lymph-nodes. The mean operating time and the mean number of lymph-nodes was 82 minutes and 26.5 nodes in patients with PLN, and 75 minutes and 12.5 nodes in patients with PALN. The overall rate of laparo-conversions was 4.5%; the incidence of major complications was 6.8% and of serious bleeding 5.6%. Laparoscopic lymphadenectomy could not be performed or completed in 2.3% of cases. Complications were more frequently associated with PALN than with PLN. SUMMARY: Laparoscopic approach to PLN and PALN is feasible in vast majority of patients. It provides adequate earnings of the lymphatic nodes, tolerable operative time, and relatively low complication rate. The highly experienced operation team for especially high infrarenal PALN is necessary.

[Is the hysteroscopy the right choice for therapy of placental remnants?]. / Je hysteroskopie správná volba pro resení reziduí tehotenských tkání?

OBJECTIVE: The evaluation of the effectiveness and safety of hysteroscopic management of residual trophoblastic tissue and to verify the miniinvasivity with the second-look hysteroscopy. DESIGN: Prospective study. SETTING: Department of Gynecology and Obstetrics, First Faculty od Medicine, Charles University and General Teaching Hospital, Prague. METHODOLOGY: From 11/2007 to 6/2011, 58 patiens with abnormal uterine bleeding longer than 6 weeks after delivery or abortion underwent ultrasound examination with fading of hyperechogenic content larger than 15mm in AP projection. There was the bipolar resectoscopic system used under general anestesia. Second-look office hysteroscopy was recommended to all patiens 4-6 weeks after a primary procedure. RESULTS: Median operative time was 15 (7-36) minutes, median time of hospitalisation was 7.1 hours. In four patients was necessary to divide the procedure into two phases (after 14 days). There was no serious uterine bleeding or inflamation in our study group. Only one serious surgical complication was registered: an uterine perforation in patient after 2 cesarean sections, there was the laparoscopic suture provided. The second-look hysteroscopy was provided in 45 patients (77.6%). There was normal intrauterine finding in 16 (35.6%) patients, in 29 patients (64.4%) a small residual trophoblastic tissue was resected. There was no secondary intrauterine adhesive process described. CONCLUSION: Hysteroscopic resection is a safe and efficient operative technique, which is suitable for management of larger trophoblastic tissue left after delivery or abortion.

[Genetic factors in etiology of uterine fibroids]. / Genetické faktory v etiopatogenezi delozních myomu.

Uterine fibroids are the most common pelvic tumors in women of reproductive age. The cause of development of uterine fibroids is still unknown, however recent cytogenetic and genetic studies led to advancement in understanding of etiology of these tumors. In accordance with the latest findings up to 40% of uterine fibroids bear some chromosomal abnormalities. The most common are aberration of chromosomes 6, 7, 12 and 14. Uterine fibroids have been linked to mutations of fumarate hydratase (FH) gene. Germline mutations in FH gene cause autosomal dominant syndromes MCUL1 (multiple cutaneous and uterine leiomyomata) and HLRCC (hereditary leiomyomatosis and renal cell cancer), characterized by multiple uterine and cutaneous leiomyomata and renal cancer. This paper reviews recent findings in the role of genetic in etiology of uterine fibroids.

Th1/Th2 cytokine gene polymorphisms in patients with uterine fibroid.

Uterine fibroid or leiomyoma is a frequent non-malignant tumour with unknown aetiology and pathogenesis. The aim of our study was to look for possible genetic markers which could be used as prognostic tools for evaluation of an increased risk for development of uterine fibroid. A large spectrum of Th1/Th2 cytokine gene polymorphisms in 102 patients with uterine leiomyoma was compared with 145 healthy controls. An association between polymorphisms of the IL4 gene promotor at positions -590 C/T and -33 C/T, and the risk of leiomyoma was observed. The CC genotype of IL4 -590 and at position -33 was less frequent in the patient group than in the control group (P = 0.03). Besides IL-4, we observed different genotype distribution of the TNFA gene -308 A/G. The frequency of genotype AA was higher in the younger (≤ 35 years) patient group (P = 0.02). Our study thus suggests that certain cytokine gene polymorphisms, especially of the IL4 and TNFA genes, may be associated with increased risk for development of uterine fibroid. Further investigation would be needed to elucidate the mechanisms responsible for these associations.

[Asherman's syndrome I--history, prevalence, histopathology, classification, ethiology, symtomatology and investigations]. / Ashermanuv syndrom I--historie, prevalence, histopatologie, klasifikace, etiologie, symptomatologie a vysetrovací metody.

OBJECTIVE: To describe the current knowledge of Ashermanes syndrome--its history, prevalence, histopathology, classification, ethiology, symtomatology and investigations. DESIGN: Review article. RESULTS: There is presented the history of definition of Asherman's syndrome. The origin of Asherman's syndrome is in a fibrotisation of endometrium--the ethiologic factors are: an intrauterine trauma in connection with pregnancy, the trauma on nongravid uterus is in minority. There is not certificated that the inflammation without trauma can cause Asherman's syndrome, exception the cases with genital TBC and schistosomiasis. The prevalence of Asherman's syndrome depends on various factors: number of therapeutic and illegal abortions, on incidence of genital inflammation and TBC, on criteria used for diagnosis of IUA and etc. The typical symptomatology of this syndrome consisted of: menstrual abnormalities (hypomenorrhea, amenorrhoea), infertility, repeated pregnancy loss and pregnancy complications. There were described a lot of classifications developed in relation with chosen diagnostic method. The gold standard in diagnosis and therapy is the hysteroscopy, the sonohysterography is very promissing diagnostic method. CONCLUSION: The Asherman's syndrome is very complicated and severe disease that can significantly influence a possibility of woman conceive and give birth to a healthy child.

[Asherman's syndrome II--therapy, methods of guidance, prevention of readhesion processs, complications and results of therapy]. / Ashermanuv syndrom II--terapie, asistencní metody, prevence readhezí, komplikace a výsledky lécby.

OBJECTIVE: To describe the current knowledge about Asherman's syndrome: methods of therapy and guidance, preventions of readhesion process, complications and results of therapy. DESIGN: Review article. RESULTS: There are presented historic and recent methods for therapy of Asherman's syndrome and their postoperative results. The hysteroscopy is the gold standard in diagnostics and therapy in this time. For prevention of perforation there are used several methods of guidance. The most frequent methods are laparoscopic and ultrasound asistence. The most actual question in this time is using of antiadhesion products for preventing of readhesion process. Between described complications belong peroperative complications and complications of consecutive pregnancy. Every patient is endangered by abortion, premature delivery, IUGR and placenta accreta or increta. The results of therapy depend on degree of intrauterine finding and previous pregnancy anamnesis. CONCLUSION: The Asherman's syndrome is very complicated and severe disease that can significantly influence a possibility of woman conceive and give birth to a healthy child.

Sentinel node (SLN) biopsy in the management of locally advanced cervical cancer.

OBJECTIVES: Sentinel lymph node (SLN) biopsy can significantly contribute to the management of locally advanced cervical cancers with high risk of lymph node (LN) positivity. However, low detection rate and sensitivity were reported in larger tumors, albeit on a small number of cases. It was the aim of our study to verify the SLN reliability in large tumors, with modified dye application technique and a careful identification of side-specific lymphatic drainage. METHODS: The study involved 44 patients with tumors 3 cm in diameter or larger, stages IB1 to IIA, or selected IIB. In cases where SLN could not be detected, systematic pelvic lymphadenectomy was performed on the respective side. Systematic pelvic lymphadenectomy was performed during the second step radical procedure if not already done. RESULTS: Detection rate in the whole cohort reached 77% per patient and 59% bilaterally. No significant difference was found whether a blue dye or a combined method was used (75% vs 80%, and 55% vs 67%). Systematic pelvic lymphadenectomy was performed in cases with undetected SLN unilaterally in 8 and bilaterally in 10 women. A systematic pelvic lymphadenectomy was included in the second step radical procedure in 19 cases and no positive LN were found. There was no case of false-negative SLN result in patients who underwent surgical treatment. CONCLUSION: Detection rate in locally advanced cervical cancer could be improved by a careful dye application technique. Low false-negative SLN rate could be achieved if pelvic lymphatic drainage is evaluated on a side-specific principle by performing systematic lymphadenectomy if SLN is not detected.

[Thermachoice thermal balloon therapy--a 10-year-experience]. / Termoablace endometria systémem Thermachoice-- 10 let zkuseností.

OBJECTIVE: To evaluate the effectivness of a global method of endometrium ablation--Thermachoice (Gynecare; Johnson & Johnson) baloon therapy in treatment of excessive uterine bleeding. Our 10-year-long-experience is presented. DESIGN: Retrospective study. SETTINGS: Department of Gynecology and Obstetrics, First faculty of Medicine, Charles University and General Teaching Hospital, Prague. METHODOLOGY AND RESULTS: 109 patients were treated in our depatment from November 1997 till the end of the year 2007. The pacients were contacted personally, over the phone and by sending questinnaires. 92 women (84.4%) were included into the evaluation group after twelve month and after 5 years there were 54 women. The group was mostly formed by seriously polymorbid patients. The average age was 41.6 years. In the twelve-month-follow-up there were 38 percent amenorrheic, five years later there were 63 percent of them. 13 women (14%) ended with hysterectomy--two pacients without any connection with the operation. In 3 cases there was a therapeutic cycle failure, because the acquired intrauterine pressure was not reached. In one case of the monstrous obese woman, after a longer period form the operation there was a carcinoma of the endometrium found out. Two women after the termoablation became pregnant: the first one non-voluntarily, she decided for the arteficial abortion and then the hysterectomy, the second one, despite the fact, that she had been fully informed, underwent the IVF therapy and at the age of 37 she delivered by the Cesarian section in the 36-week-old pregnancy the healthy girl weighing 2900 gramms. With one patient--a young woman the operation was combined with uterine artery embolisation (UAE)--and that is why she was excluded. 51.5% of all operations were perfomed without general anestesia. There was no serious complication in the observed group. CONCLUSION: The big advantage of the second generation ablation methods is the possibility to realise the operation without the general anestesia and with the minimum discomfort for the patient. Another favourable circumstance was the shorter determined operating time and lower percentage of complications in comparison with the first generation methods. The big benefit is mainly for the seriously polymobid pacients.

[Sexual functions after laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) in preoperatively asymptomatic women]. / Sexuální funkce po laparoskopicky asistované vaginální es gynek. hysterektomii (LAVH) a totální laparoskopické hysterektomii (TLH) u predoperacne asymptomatických zen.

OBJECTIVE: To find the consequences of laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) for sexual functions in preoperatively asymptomatic women. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Teaching Hospital in Prague. MATERIAL AND METHODS: In 100 women without subjective complaints hysterectomy was performed for benign uterine pathology. In all the women the uterus weighted less than 250 g, there were no salpingooophorectomies and no perioperative complications. Women were alternativelly assigned for LAVH (n = 50) or TLH (n = 50). Clinical documentation and questionnaires about sexual functions were evaluated in 87 women (in 40 women after LAVH and in 47 after TLH) 18 months after surgery or later. RESULTS: According to our findings the type of surgery did not influence the frequency of sexual activity after surgery, there was no change in sexual manners using during coitus as well as no change in preferred way how to reach the sexual arousal (clitoridally, vaginally or combined). The type of surgery did not influence frequency, quality and duration of orgasm. From all the evaluated parameters there were only two significantly different: the presence of postoperative sexual activity (positive answer in all women from LAVH group and only in 85% women from TLH group, F test, p = 0.009) and the frequency of sexual satisfaction (in terms of both increase and also decrease in TLH group chi2 8,376, p = 0.015). CONCLUSION: The type of laparoscopic hysterectomy (LAVH or TLH) does not significantly affect the sexual functions (frequency of sexual satisfaction, type of sexual arousability, intensity and duration of orgasm) in preoperatively asymptomatic women.

[News and perspectives in uterine fibroids radiotherapy]. / Novinky a perspektivy v radiologické lécbe delozních myomu.

Uterine artery embolization (UAE) represents radiological treatment of uterine fibroids. It is highly effective and safe mainly in premenopausal patients with symptomatic fibroids and represents an alternative to hysterectomy in a group of women not suitable for minimally invasive surgical treatment (LAVH) and women desiring uterus sparing therapy. The future of UAE lies in optimal selection of patients based on volume-shrinkage prediction and fertility outcome. The second group is represented by methods based on direct fibroid tissue destruction using specific energy under MRI or UZ guidance. The common aim of these two groups is the volume shrinkage as well as the symptomatic relief. The second group is represented by radiofrequency ablation, focused ultrasound surgery, interstitial laser ablation and cryotherapy. Based on their non-surgical, percutaneous approach these can be classified as minimally-invasive methods. The second group of methods is suitable only for patients with the absence of any desire for child bearing due to the absence of their long-term outcome data.

[Methods using ischemia in uterine fibroids treatment]. / Ischemizující metody lécby delozních myomu.

OBJECTIVE: To compare principle, advantages, disadvantages, and risks of conservative (i.e. uterus saving) methods of treatment of uterine fibroids, which are focused on elimination or reduction of their perfusion. To contribute to better understanding of this dynamic topic between gynecologists, especially in the field of appropriate indication criteria. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, Charles University and General Faculty Hospital, Prague. METHODS: Analysis of literature and our clinical experience. CONCLUSIONS: Within the last decade the spectrum of treatment of uterine fibroids has broaden with methods causing ischemia of fibroids. These include the minimally invasive surgical therapy (laparoscopic occlusion of uterine arteries /LUAO/ and Doppler assisted laparoscopic myolysis) and radiological catheterization treatment (uterine artery embolization, UAE). Compared to foreign countries where UEA is mainly used in perimenopausal women, we focus on the group of patients with further fertility plans. It is necessary to stress that in spite of the number of affirmative experiences with the new techniques of uterine fibroid treatment in both the indication groups (women with or without further fertility plans) these methods still remain an alternative to standard surgical treatment, because both myomectomy and hysterectomy can be performed by minimally invasive techniques in the majority of women. This review is also focused on the specific risks of the particular methods as well as on their mechanism of action which may dramatically differ despite of some analogies.

[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.

Tubulo-squamous polyp of the vagina.

We report a case of an 86-year-old female with a tubulo-squamous polyp of the vagina. Grossly, the polyp measured 2 x 1.5 x 1 cm. Histologically, it was composed of well-circumscribed nests of squamous cells with bland nuclei. Some of the squamous nests showed central spaces filled with necrotic debris. Small tubules were present at the periphery of some of the nests, and there were a few tubules unassociated with the squamous nests. Furthermore, several larger mucinous glands, some with apparent squamous metaplasia, were present. The stroma was fibrous and rather hypocellular. Surface of the polyp was covered by intact squamous epithelium, which was not connected with the underlying lesion. The recently described tubulo-squamous vaginal polyp represents a distinctive entity. To the best of our knowledge, only one study describing a series of ten cases has been reported in the literature to date.

[Etiopathogenesis of uterine fibroid: current knowledge]. / Soucasné poznatky o etiopatogenezi delozních myomu.

OBJECTIVE: To sum up the knowledge of etiology and pathogenesis of uterine fibroids. TYPE OF STUDY: Review. SETTING: Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University, Prague. SUBJECT OF STUDY: A summary of what is known about development of uterine fibroids. CONCLUSION: In this overview of etiology and pathogenesis of uterine fibroids we have attempted to ananlyze the literature and present prevailing evidence and opinions.