[Corpus alienum in the uterus--diagnostic and therapeutic hysteroscopy].

The aim of the authors is to assess the potentialities and the application of hysteroscopy for diagnosis and treatment in cases of foreign body in the uterine cavity. Twenty eight women with different kinds of foreign bodies are included in the research: 17 patients with "lost" IUD in utero after failed attempts for blind extraction; 4 cases with unresorbed sutures after cesarean section; 1 case of uterine tamponade, incorporated in the uterine cesarean suture; 5 cases of residual tissue after interrupted pregnancies and unsuccessful D&C. The clinical symptoms, the hysteroscopic findings, the used equipment, the complications and the postoperative results are described. A conclusion is made about the advantages of the hysteroscopy over the "blind" extraction and, for this reason, that hysteroscopy should be the method of choice for diagnosis and treatment in case of corpus alienum in the uterus.

[Seven-year-experience in the hysteroresection of submucous myomas].

AIM OF THE RESEARCH: to summarize the results of hysteroscopic resections of submucous myomas, performed in the last 7 years in our clinic and to compare the results with those cited in the literature. MATERIAL AND METHODS: 124 women at the age of (from) 24 to 66 years were operated, 63 of them (50.6%) were under 40 years and 42 women (33.9%) were nulliparous. The main complaints were abnormal uterine bleedings, pains and reproductive problems. RESULTS: 142 submucous myomas were resected. The mean diameter was 32.15 mm (from 5 to 55 mm); 8 myomas were 50 mm and more in diameter. The mean operational time was 33.4 min. The intraoperative complications were 3.2% (4 cases)--2 cases of bleeding and 2 cases of uterine perforation. Hospital stay--89 women (71.8%) were dehospitalized 24 hours after the operation and the other 32 women (28.2%)--8 hours after the operation. The postoperative follow-up included: 97 women--to 6 months, 83 women--to 1 year, 65 women--to 2 years and 31 women--to 3 years. The abnormal uterine bleedings disappeared in 100% of the cases which were followed up to 6 months. After 3 years 7 women, out of 31 observed, had abnormal bleeding; 5 women underwent hysterectomies because of intramural myomas, atypical endometrial hyperplasia, endometrial cancer, uterine prolapse. Eight of the women (47.0%) with reproductive problems became pregnant and 5 of them have already given birth (one of them--twice). The operative time, complications, postoperative hospital stay and the effect on the clinical symptoms were similar to those cited in the literature. CONCLUSION: The results of the study confirmed the advantages and the excellent potentialities of the hysteroscopy in the treatment of the submucous myomas. The method is extremely atraumatic, organ-preserving and highly effective in the elimination of the clinical symptoms. For this reason hysteroscopy should be the method of choice for treatment of the submucous myomas.

[Hysteroscopy in cases of benign intrauterine formations in the postmenopause].

UNLABELLED: Submucous myomas and especially endometrial polyps are often found in the postmenopause. There are no reliable clinical or ultrasound criteria to predict their malignancy potential. The D&C is insufficient diagnostic and therapeutic method in case of benign intrauterine formations. The potentialities of the hysteroscopy make it a particularly appropriate method in these cases. AIM: The aim of the research is to estimate the results of the applying of the hysteroscopy in the postmenopause for diagnosis and treatment of the benign intrauterine formations. MATERIAL AND METHODS: The research included 62 women in postmenopause with bleeding, pains or sonographically-found formations in the intrauterine cavity. Their age varied from 50 to 78 years and 62.3% of women were over 55 years. Thirty patients suffered from serious concomitant illnesses. Seventeen of the women had already undergone one or more D&C. RESULTS: Hysteroscopy with resection of the formations was performed in all of the cases. Eighty formations have been evacuated--18 submucous myomas and 62 endometrial polyps. The average size of the submucous myomas was 24.0 mm (from 5 to 70 mm). The average operational time in the cases of endometrial polyps was 15.2 min. (from 5 to 50 min) and 18.3 min. (from 10 to 40 min.)--in the cases of submucous myomas. Intraoperational complications developed in two of the cases (heavy bleeding and perforation). Forty nine patients have been observed postoperatively. Out of 14 women with submucous myomas 10 have been observed and all of them had no complaints or recurrences. Thirty nine out of 48 women with endometrial polyps have been observed and 36 of them had no complaints or indications of a recurrence. In one case a new polyp was found after two years and a new hysteroresection was performed. Two women underwent hysterectomy subsequently because of bleeding and endometrial hyperplasia. DISCUSSION: The hysteroscopic polypectomy is an effective and harmless procedure. It gives the possibility that the object be seen, localized, sampled and evacuated entirely. The approach is miniinvasive, the general anesthesia and laparotomy is avoided. This is especially important for women with serious concomitant diseases. A histological examination of the whole formation is possible. CONCLUSION: Hysteroscopy is the most appropriate modern method for diagnosis and treatment of benign intrauterine formations in the postmenopause.

[Diagnostic problems in a case of fibroma ovarii].

Fibroma ovarii is a solid benign tumor which consists of fibrous tissue. It is usually hard, but there may be small cystic spaces due to degenerative changes. The incidence of fibroma ovarii is about 8 to 10%. The authors present a case of this tumor with difficulties in diagnosis before operation.

[Hysteroscopy in women with reproductive problems].

UNLABELLED: Authors discuss the potentialities of hysteroscopy in revealing the causes of sterility and infertility. AIM: to establish the most common hysteroscopic findings in women with reproductive problems and the results of the performed hysteroscopic procedures. DESIGN: prospective study. RESULTS: Out of 360 hysteroscopic operations, 76 have reproductive problems (sterility, spontaneous abortions, premature deliveries). In the group of women with primary sterility the most common findings were endometrial polyps (56.8%) and submucous myomas (31.8%); in the group with secondary sterility - intrauterine synaechia (50.0%) and corpus alienum (25.0%); patients with habitual abortions had most frequently uterine septum (46.7%). Postoperative follow up of 44 women showed 72.7% reproductive success after the hysteroscopic procedures. CONCLUSION: For women with reproductive problems, hysteroscopy is a reliable method for almost 100% detection of the intrauterine pathology and for, in a great extend, of its elimination.

[Lactofem--using of vital lactic acid bacteria in the cases of vaginal microflora imbalance].

The authors describe the microbiological content of the vaginal ecosystem in healthy, reproductive aged women, as well as women with different types of vaginitis, and the recovering possibilities that LACTOFEM offers. It contains vital H2O2 - producing Lactobacillus acidophilus and Lactobacillus rhamnosus.

[Torsion of a nongravid leiomyomatous uterus].

The torsion of a nongravid uterus is not of frequent occurence. The leading reasons are a presence of an adnexial formation or leiomyomas. In this case report it has been presented a 65-year old patient with a hard abdominal pain. After the gynecologic and ultrasound examination it has been found an uterus myomatosus with three intramural-subseros leiomyomas. By the following laparotomy was confirmed the ultrasound results - the uterus with big intramural-subserous leiomyoma 8-9 cm in a diameter, and two more leiomyomas - 5 cm, a torsion of the body uterus at 180 degree above the vaginal part of the cervix. The adnexes were rotated around the supravaginal (isthmic) part of the uterus, the uterine tubes were hyperemic, swollen, with livid color, and the ovarian were atrophic. Total hysterectomy with bilateral adnexectomy was performed. We suggested that the main reason for this torsion of the uterus was the presence of leiomyomas and the genital descensus played a role as a predisposition.

[Bony fragments in the uterus cavity].

A rare kind of uterine pathology is considered in the article--the presence of bony fragments in the uterine cavity. Three cases with such findings are cited. Pathogenesis, clinical symptoms, diagnostic and therapeutic methods are discussed.

[Intrauterine infection in cases with premature rupture of fetal membranes--incidence, structure].

OBJECTIVE: The study deals with the question about the real incidence of the intrauterine infection (IUI) after PROM; the correlation between the clinical manifestation of IUI and histological findings as well as its relationships with the incidence of the neonatal infections. DESIGN: Prospective study. METHODS AND PATIENTS: One hundred eighty two pregnant women with premature delivery and their newborn infants were included. Clinical and laboratory signs concerning the presence of IUI were followed. A histological study of the fetal membranes, cord and placenta was done classifying the inflammatory changes according to there severity. The newborn infants were observed for signs of neonatal infection. Juxtaposition between the clinical manifestation of the IUI and the morphological signs of inflammation in the fetal membranes, cord and placenta was done. RESULTS: In 114 women histological signs of IUI were found but clinical signs of IUI were observed in only 51 cases (44.7%), i.e. in the other 63 cases the infection ran subclinically. An incidence of 11.5% (21 cases) of neonatal infection after PROM was registered and in 20 of them there were histological signs of intrauterine infection (in 14 cases with umbilical cord involvement--66.7%). CONCLUSION: The cases with clinically manifested IUI do not reflect the real incidence of IUI--in about 34.5% of women with premature delivery infections run subclinically. There is a strong relationship between inflammatory changes in fetal membranes, cord and placenta and the neonatal infections. Among cases with severe inflammation (with fetal cord involvement) about one third of the newborn infants develop neonatal infections.

[Intrauterine infection in premature rupture of fetal membranes--dynamics].

UNLABELLED: One of the controversies in the theoretical and practical obstetrics is the relationship between the length of the latent period after the PROM and the incidence of the intrauterine infection (IUI). AIM OF THE STUDY: To establish how the incidence of IUI changes with the duration of the latent period after PROM. DESIGN: Prospective study. METHODS AND PATIENTS: Five hundred seventy six pregnant women with PROM and their newborn infants were included. The clinical, laboratory and histological signs of IUI were observed. The incidence of the cases with clinically manifested IUI, histologically approved IUI and neonatal infections at different length of the latent period were explored. RESULTS: The incidence of the inflammatory changes in the fetal membranes, umbilical cord and placenta increased progressively with the prolongation of the latent period, respectively--in 34.4% after 24 hours, 52.0% after 48 hours, 87% after the 72-th hour. Inflammatory changes in umbilical cord rised sharply from 8.0 to 47.8% after 72 hours from the PROM. Clinically manifested IUI and neonatal infection also rised sharply after the 72-th hour after the PROM, respectively--at 62.9% and 22.5%. CONCLUSION: There is a relationship between the incidence of the infectious complications and the duration of the latent period after the PROM. The risk of IUI rises sharply between the 24-th and the 72-th hour after the PROM.

[Using GnRH-agonists (Zoladex) in the treatment of genital endometriosis].

METHODS AND MATERIALS: The study is prospective and involves 112 patients suffering from pelvic endometriosis aging from 19-38 years. (28.6 average age). The disease was diagnosed via laparoscopy and the stage was determined using the revised AFS classification. Zoladex (Goserelin depot--3.6 mg) is being applied every 28 days for 6 months in the hypodermic tissue of the front abdomen wall. All patients are being examined monthly after every Zoladex application (for subjective complaints--dysmenorrheal, dyspareunea, pelvic pain; serum estradyol-E2; amenorrhea; side effects) and every 24 months (recuperation of the menstrual cycle, pregnancy). RESULTS: In 88% of the patients amenohrea is obsereved in the first eight weeks of therapy. The menstrual cycle takes an avarege of 68 (31-139) after the last Zoladex application to reappear. At the end of the first month after the first application the serum level of estradyol E2 is lowered to a menopause level (from 750-800 to 120-130 Pmol/L) and it remains as low till the end of the treatment. Eight weeks after the completion of the therapy it goes back to its normal values. During the course of the first month of amenorrhea condition a 38% fall in the level of complaints (dysmenorrheal, dyspareunea, pelvic pain) is observed. After the 6th month 88% of the patients have no complaints. Side effects observed during the course of treatment include warm waves, sweating, vaginal dehydration (60-80%) which do not in any way disturb the patients to the point of quitting the therapy and do disappear with its end. The focus group contains 54 infertile patients with endometrioses willing to get pregnant. In 12 months after the completion of the treatment 16 of the patients become pregnant, followed by 12 more in the next one year. CONCLUSION: Zoladex causes amenorrhea, which lasts till the end of the treatement. It causes a rapid drop of the serum consentration to a menopause level. Causes a strong and durable treatment of the symptoms of endometriosis. The side effects disappear with the end of the therapy. The treatment is easy to go through and there no cases of a quitting patient. The treatment has a curable effect over the endometriosys and in cases of infertility provides a possibility for pregnancy.

[Acute intermittent porphyria and pregnancy (case report)].

A case of acute intermittent porphyria [AIP] known before pregnancy is reported in a patient who delivered by elective caesarean section. The pathogenesis of the disease, its symptoms and diagnosis are described as well as specific aspects of its clinical manifestation and differential diagnosis during pregnancy The therapeutic approach both during and out of pregnancy is discussed.

[Cytolytic vaginosis--clinical and microbiological study].

47 women at reproductive age were diagnosed with cytolytic vaginosis according to their clinical and microbiological findings, including abundant lactobacilli/score 0 by Nugent/, free nuclei due to cytolysis, paucity of leucocytes, over 200 colony of HP/+/Lactobacillus spp., but no fungal growth. Heavy growth of HP/+/Lactobacillus spp. creates conditions under which the intensified cytolysis, displayed as abundant fluor, is likely to be due not only to the increased quantity of lactic acid but as well as to hyper production of hydrogen peroxide. 32 patients report improvement of their condition after at an average of 2 cycles of vaginal douches with sodium bicarbonate.

[Hysteroresection of submucous myomas after treatment with zoladex].

UNLABELLED: The early and heavy clinical symptoms of the submucous myomas demand early surgical intervention. The new alternative to the classical abdominal operation is the transcervical hysteroresection which is miniinvasive and organ-preserving procedure. OBJECTIVE: to assess the effect of the preoperative treatment of the patients with Goserelin acetate (Zoladex) on the intraoperative measures (operation time, intraoperative complications, difficulty of the procedure). STUDY DESIGN: prospective. PATIENT(S) AND METHODS: Total of 50 women with submucous myomas underwent hysteroresection. Ten of them were treated with Zoladex for two months preoperatively. RESULTS: In the treated group a mean decrease of 10.16 mm of the myoma diameter was achieved. This is especially important for myomas above 30 mm in diameter because 10 mm decrease in diameter leads to significant reduction of the tissue volume which has to be resected. In the treated group the mean operation time was decreased by 17.08 min. and the operation was assessed as "easier" in 90% of the cases. The authors assessed that the positive effect of Zoladex consists not only of the decreasing of the myoma diameter but also of achieving an endometrial atrophy which significantly improves the conditions for performing the intrauterine operation. CONCLUSION: Hysteroscopic resection of submucous myomas after pretreatment with Zoladex is faster, easier and with less intraoperative complications.

[A rare case of a Mullerian tract anomaly].

A case of a Mullerian tract defect in a 26-years old patient is reported. The anomaly is detected during an undesired pregnancy. Diagnostic methods used in that case are described. Diagnostic difficulties in determining the type of the defect and classifying it according to AFS classification (1988) are discussed. The variety of Mullerian tract defects and necessity of individually designed plan for diagnosis and treatment of every particular patient are discussed.

[Modern treatment of early-stage cervical cancer].

AIM: In our study we tried to summerise our and foreign experience in the area of early stages of cervical cancer treatment MATERIAL AND METHODS: We examined 500 patients with early stage cervical cancer for 10 years period (1996-2006). RESULTS: We analised the following important factors when treating the early stages cervical cancers: the histopathology type of tumour, the type of the conisation, the number of the tissue sections, the resection line numbers, the LVSI and the desire of the patients to preserve fertility. CONCLUSIONS: When treating lesions with depth of invasion 1-3 mm we may use conosation if there is no invasion in the LVSI. If there is invasion we used lymph node dissection. For lesions with depth of invasion from 3-5 mm the optimal treatment regimen is simple hysterectomy with lymph node dissection both sides. In stage IB cervical cancer we used the best treatment choice: radical hysterectomy with pelvic lymph node dissection.

[Complications following surgery and radiotherary in 108 patients with cervical cancer].

OBJECTIVE: To evaluate the most common complications following surgery and radiotherary of cervical cancer based on own experience and to compare them to the complications rates reported by other authors. MATERIAL: One hundred eight patients with invasive cervical cancer, staged (IB-IVB) are enrolled in the study. They all had been operated on in Varna between the period XI.2003-VI.2006 by the author. METHODS: Surgical management includes radical hysterectomy class ll-IV, selective and total pelvic and paraaortic lymph node dissection. Radiotherapy is preoperative 30-52 Gy and adjuvant postoperative 52 Gy TGT Cisplatin-based neoadjuvant chemotherapy had been administered 3 courses at intervals of 21 days before surgery. Peritonization with two retroperitoneal drains in fossa obtoratoria had been performed in 91 patients. Seventeen patients were non-peritonized with abdominal drianage. RESULTS: In the group of patients with peritonization and retroperitoneal drainage the incidence rates of fistulas,lymphocysts, ureteral strictures, urinary infections, ileus, radiation-induced proctitis are: 1,1%, 5,5%, 2,2%, 3,3%, 1,1% and 2,2%, respectively. In the group of patients without peritonization the incidence rates of same complications are: 5,9%, 17,6%, 0%, 0%, 29,4% and 11,8%, respectively. CONCLUSION: Pelvic peritonization and retroperitoneal drainage decreases significantly the early and late postoperative complications, especially the incidence rate of fistulas, lymphocysts, lymphedema, ileus, radiation- induced proctitis and proctosygmoiditis and makes them comparable to these complication rates,reported by other authors and centres. This method allows the patients to be discharged at the light postoperative day, optimizes the quality of life and the survival.

[Endometrial cysts of the vagina and the vulva (case reports and a literature review)].

Two cases of low-genital-tract-endometriosis are presented. First case is of a big endometriotic cyst of the labia minor, clinically presented as a Bartholin's gland cyst. Second case represents a vaginal cyst which mimics urethral diverticulum. In each case the final diagnosis was determined after the hystopathologial examination. A briefe literature review was done. Endometriotic cysts of the vagina and vulva are rare. Usually they mimic other, more frequently encountered lesions. Not always they have the typical symptoms of endometriosis and there diagnosis is rare determined before the surgical procedure and hystopathological examination. A detailed anamnesis, thorough clinical examination and additional methods (cystoscopic. imaging, sonographic) are needed for the diagnosis. Management consists of a surgical removal of the lesions, hormonal suppression of the ovarian function and, by all means, following up the patients for appearance of a recurrence or of a lesion de novo.

[Localization of leiomyoma with respect to the placenta--factor for complications during pregnancy?].

We are presenting two cases of pregnant women with leiomyoma of the uterus, diagnosed antepartum. In both cases the patients were admitted on an emergency basis due to premature uterine contractions. In both cases preterm hemorrhage and fetal malpresentations were observed. The complications of pregnancy in both of the cases were primarily based on the location of the leiomyoma with respect to the placenta--intramural or submucosal disposition of the leiomyoma, retroplacentarily situated.