Transabdominal punction of follicular fluid in IVF cyclus in a patient after ovarian transposition.

OBJECTIVE: Description of punction of follicular fluid in a patient after ovarian transposition. DESIGN: Case report. SETTING: Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University and the General Faculty Hospital, Prague. CASE REPORT: We present a case of IVF treatment in a patient with ovarian transposition undergoing punction of follicular fluid and difficulties during this procedure acording to transabdominal route. CONCLUSION: Transabdominal punction od follicular fluid is possible, but with technical difficulities and smaller amount of obtained oocytes. We recomend to aplicate IVF procedures prior to surgical solution.

Fetal and neonatal alloimmune thrombocytopenia.

OBJECTIVE: This article shows our experience with fetal and neonatal alloimmune thrombocytopenia (FNAIT) on a particular patient and the difficulties we faced during the hospitalization. DESIGN: Case report. SETTING: Department of Obsterics and Gynecology 1st Faculty of Medicine, Charles University and General Faculty Hospital in Prague. METHODS: Our experience with FNAIT therapy. RESULTS: According to literature is recommended to use IVIG for FNAIT treatment. Women, who were treated by IVIG have better results, in comparison with women, who had no treatment at all. Our case is not confirming this statement, because first pregnancy of our patient terminated by IUFD, on the other hand second pregnancy was successful and she delivered healthy child. CONCLUSION: FNAIT is relatively rare disease, but if it appears, it can be dangerous for a fetus or for a new-born baby. In the worst case FNAIT can result in intracranial bleeding or prenatal death. There are limited preventive steps and available therapy produces uncertain results. The only partially accepted treatment substance is IVIG (intravenous immunoglobulins). Unfortunately, this therapy is very expensive and not accepted by some experts. This article shows our experience with FNAIT on a particular patient and the difficulties we faced during the hospitalization.

[Spontaneus delivery after two previous caesarean sections - case report]. / Spontánní porod po dvou císarských rezech a jeho mozné komplikace - kazuistika.

OBJECTIVE: To demonstrate the higher risk of the uterine dehiscence/rupture in spontaneously delivering women with scared uterus. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, General Teaching Hospital in Prague and First Medical School, Charles University. CASE REPORT: We demonstrate the risk of uterine dehiscence on the example of 36 year-old woman with two previous caesarean sections who decided to give birth spontaneously. CONCLUSION: The scars on uterus are the risk factor for uterine dehiscence and rupture. In present, the rising number of caesarean sections leads to increasing number of women with scars on uterus. Despite the potential risk of scars on the uterus, small number of women with history of surgery on uterus plans to give birth spontaneously. We demonstrate the higher risk of the uterine dehiscence after spontaneous delivery in woman with history of two caesarean sections and successful conservative therapy.

Detection of fetal major structural anomalies at the 11-14 ultrasound scan in an unselected population.

OBJECTIVE: The aim of the study was to determine the efficacy of the 11-14 week scan in detecting fetuses with structural anomalies. STUDY DESIGN AND METHODS: Prospective interventional study in an unselected population of pregnant women in a 5-year period (2003-2008) in a single ultrasound unit. 8889 fetuses with median CRL 65mm (45-84mm) were examined. Continuing pregnancies were rescanned at 20-22 weeks. Actual structural anomalies among newborns from the studied group were obtained from our computerized database. RESULTS: The median maternal age was 30 years (14-50 years). The incidence of anomalies was 16.08 per 1000 (143/8889). Of these, 99 of the 143 were detected with prenatal sonography. 46.9% (67/143) of all anomalies were detected at the 11-14 week scan. Later in pregnancy, another 22.3% (32/143) of structural anomalies were detected. CONCLUSIONS: 67.7% of all antenatally detected malformations by ultrasound were recognized in the 11 14 week scan. Obviously, the second trimester scan cannot be abandoned, as it provides effective detection of other anomalies.

[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.

The branching pattern of villous capillaries and structural changes of placental terminal villi in type 1 diabetes mellitus.

Maternal diabetes is associated with changes of the placental structure. These changes include great variability of vascularity manifested by strikingly hypovascular as well as hypervascular terminal villi. In this paper, normal placental terminal villi and pathological villi of type 1 diabetic placentas were compared concerning the structure of villous stroma, spatial arrangement of villous capillary bed and quantitative assessment of capillary branching pattern. Formalin fixed and paraffin embedded specimens of 14 normal and 17 Type 1 diabetic term placentas were used for picrosirius staining, vimentin and desmin immunohistochemistry and confocal microscopy. 3D models of villi and villous capillaries were constructed from stacks of confocal optical sections. Hypervascular as well as hypovascular villi of diabetic placenta displayed changed structure of villous stroma, i.e. the collagen envelope around capillaries looked thinner and the network of collagen fibers seemed less dense. The desmin immunocytochemistry has shown that stromal cells of hypervascular as well as hypovascular villi appeared nearly or completely void of desmin filaments. In comparison with normal villi, capillaries of hypovascular villi had a smaller diameter and displayed a markedly wavy course whereas in hypervascular villi numerous capillaries occurred in reduced stroma and often had a large diameter. The quantitative assessment of capillary branching has shown that villous capillaries are more branched in diabetic placentas. It is concluded that type 1 maternal diabetes enhances the surface area of the capillary wall by elongation, enlargement of diameter and higher branching of villous capillaries and disrupts the stromal structure of terminal villi.

[Accuracy of placenta accreta ultrasound prediction in clinical work]. / Moznosti ultrazvukové predikce placenta accreta v klinické praxi.

OBJECTIVE: To evaluate accuracy of placenta accreta ultrasound prediction in own group of patients. DESIGN: Retrospective analysis. SETTING: Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague. METHODS: We retrospectively evaluated a group of 12 patients, that had undergone ultrasound examination during pregnancy at our department and afterwards had been diagnosed during caesarean section (CS) with placenta accreta (years 2010-2011). RESULTS: 11 out of 12 women in our group had at least one of the risk factors (placenta praevia, previous SC, history of uterine surgery). During US examination, suspicion of placenta accreta was raised at 7 out of 12 women. In 5 cases we have performed elective CS and in 7 cases CS was done after onset of the labour (in 4 cases the reason was severe bleeding). The peripartal blood loss ranged from 500 ml to 7000 ml. Due to life threatening bleeding in 5 cases (42%), abdominal hysterectomy was performed. Placenta accreta was successfully diagnosed in cases with hysterectomy by US in 80 percent (4/5). Histological examination of the uterus confirmed in 2 cases placenta accreta, in 2 cases placenta increta and in 1 case placenta percreta. CONCLUSION: US diagnosis of placenta accreta is possible, with success rate of 58 percent (7/12). Early diagnosis helps to properly set up CS and consult the patient about the risk of unavoidable hysterectomy.

Autofluorescence of the fungus Morchella conica var. rigida.

Autofluorescence (primary fluorescence (AF)) of fruiting bodies and stems of the fungus Morchella conica var. rigida was studied by fluorescence microscopy including sporangia and ascospores. The ascospores were characterized by a weak green-yellow AF at blue excitation. Using a green excitation, no AF was observed. The hyphae located under the layer of asci with ascospores exhibited a higher primary fluorescence, namely their walls that had green-yellow color at blue excitation. Also, their red AF observed when a green excitation was used was significant. Similarly, the hyphae located in the fungal stem exhibited a significant AF, especially their walls when the blue light was used for excitation. In addition, large, yellow-to-yellow/green, oval-to-round bodies with strong fluorescence were detected whose morphological equivalents were not clearly visible in the white halogen light. The AF of the fungus M. conica var. rigida was lower compared with the other higher fungi studied so far.

Pericyte coverage of fetoplacental vessels in pregnancies complicated by Type 1 diabetes mellitus.

Placentas from pregnancies complicated by Type 1 diabetes mellitus (DM 1) display altered vascular morphology and function. Here we studied the extent of pericyte coverage in microvessels of normal pregnancies and pregnancies complicated by DM 1. We used smooth muscle actin (SMA) as a marker for quantitation of pericyte coverage in placental capillaries. The extent of pericyte coverage around the vessel circumference was 38 ± 11% in normal vs. 33 ± 10% in DM 1 pregnancies. We found that there is no statistically significant difference in the extent of pericyte coverage around the capillary circumference between DM 1 and normal pregnancies.

[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.

Is maternal progesterone actually independent of the fetal steroids?

Progesterone and estradiol are the foremost steroid hormones in human pregnancy. However, the origin of maternal progesterone has still not been satisfactorily explained, despite the generally accepted opinion that maternal LDL-cholesterol is a single substrate for placental synthesis of maternal progesterone. The question remains why the levels of progesterone are substantially higher in fetal as opposed to maternal blood. Hence, the role of the fetal zone of fetal adrenal (FZFA) in the synthesis of progesterone precursors was addressed. The FZFA may be directly regulated by placental CRH inducing an excessive production of sulfated 3beta-hydroxy-5-ene steroids such as sulfates of dehydroepiandrosterone (DHEAS) and pregnenolone (PregS). Due to their excellent solubility in plasma these conjugates are easily transported in excessive amounts to the placenta for further conversion to the sex hormones. While the significance of C19 3beta-hydroxy-5-ene steroid sulfates originating in FZFA for placental estrogen formation is mostly recognized, the question "Which maternal and/or fetal functions may be served by excessive production of PregS in the FZFA?" - still remains open. Our hypothesis is that, besides the necessity to synthesize de novo all the maternal progesterone from cholesterol, it may be more convenient to utilize the fetal PregS. The activities of sulfatase and 3beta-hydroxysteroid dehydrogenase (3beta-HSD) are substantially higher than the activity of cytochrome P450scc, which is rate-limiting for the placental progesterone synthesis from LDL-cholesterol. However, as in the case of progesterone synthesis from maternal LDL-cholesterol, the relative independence of progesterone levels on FZFA activity may be a consequence of substrate saturation of enzymes converting PregS to progesterone. Some of the literature along with our current data (showing no correlation between fetal and maternal progesterone but significant partial correlations between fetal and maternal 20alpha-dihydroprogesterone (Prog20alpha) and between Prog20alpha and progesterone within the maternal blood) indicate that the localization of individual types of 17beta-hydroxysteroid dehydrogenase is responsible for a higher proportion of estrone and progesterone in the fetus, but also a higher proportion of estradiol and Prog20alpha in maternal blood. Type 2 17beta-hydroxysteroid dehydrogenase (17HSD2), which oxidizes estradiol to estrone and Prog20alpha to progesterone, is highly expressed in placental endothelial cells lining the fetal compartment. Alternatively, syncytium, which is directly in contact with maternal blood, produces high amounts of estradiol and Prog20alpha due to the effects of type 1, 5 and 7 17?-hydroxysteroid dehydrogenases (17HSD1, 17HSD5, and 17HSD7, respectively). The proposed mechanisms may serve the following functions: 1) providing substances which may influence the placental production of progesterone and synthesis of neuroprotective steroids in the fetus; and 2) creating hormonal milieu enabling control of the onset of labor.

Enhancement of autofluorescence of the brown-rot fungus Piptoporus betulinus by metal ions.

The autofluorescence (primary fluorescence, AF) of agar cultures of the brown-rot fungus Piptoporus betulinus was investigated in Zeiss Jenalumar and Nikon Eclipse 8201 fluorescence microscopes at various excitations. The strongest AF of hyphae was found in minimal medium with glucose, where the hyphae exhibited green AF at violet (450 nm) excitation and red AF at green (570 nm) excitation. Addition of metals to cultivation media led to enhanced white-blue AF in the presence of Co (at 450 nm) and yellow to yellow-brown AF at 510 nm. When cultivated with Mn and Zn, enhanced AF of intracellular content was observed. Only a weak signal was found in the presence of Cu and Fe.

Newly designed, simple relief phase contrast for microscopy of microorganisms.

A new method providing a relief phase contrast for investigation of microorganisms by optical microscopy used a neutral filter Zeiss NG 10/1 that could be controllably slid at a certain azimuthal angle below the aperture condenser diaphragm of the microscope phase contrast. Two ways of application are described depending on the type of the microscope: (1) in a special holder, and (2) fixed on a rubber ring. The device enabled us to obtain excellent results in the area of both optical microscopy and microphotography. With the microorganisms visualized, a better resolution, higher contrast and a significant 3D effect were obtained; outer morphology and organelles (chloroplasts, nuclei, granules, oil reserve vacuoles, etc.) could also be investigated.

[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.

A new type of relief condenser for the study of microorganisms.

A new type of relief condenser mounted on a current laboratory microscope produced by Lambda Praha was used for the study of microorganisms of two kingdoms, Chromista and Plantae. The pictures obtained by the use of this device had a better resolving power and remarkable contrast, and a well visible 3D effect. Because of the absence of an aperture diaphragm the use was much simpler, compared to relief condensers whose construction was different.

Prenatal diagnosis and neonatal management of anorectal malformation--a case report.

Intestinal dilatation and hyperechogenic bowel, some typical ultrasonographic features of anorectal malformation, were found in the 21st week of a singleton pregnancy. These findings were associated with unilateral renal agenesis and a single umbilical artery. All prenatally diagnosed anomalies were confirmed postpartum. Development of the sonographic appearance of the anorectal malformation, prenatal and neonatal management are described and discussed.

[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.

[Prenatal intracranial hemorrhagie--diagnosis and follow-up]. / Prenatálne vzniklé intrakraniální krváicení--diagnostika a sledování.

AIM: We present a case of difficult prenatal diagnosis and follow-up of severe fetal intracranial hemorrhage. With an analysis of the available literature that is related to this topic, we would like to bring attention to the necessity of accurate evaluation of fetal brain morphology even during routine ultrasound examination in the late third trimester. TYPE OF STUDY: Case report. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague. METHODS AND RESULTS: Four cases of prenatal intracranial hemorrhage are presented. All cases were diagnosed during ultrasound examination during the third trimester of pregnancy and the findings were clarified using nuclear magnetic resonance imaging. The etiology of the hemorrhage was determined in only two cases. Postnatal follow-up of the affected children over a range of one to two years of age shows a very severe prognosis of the described hemorrhagic conditions. CONCLUSION: Prenatally diagnosed fetal intracranial hemorrhage is a rare but severe complication in pregnancy associated with fetal and neonatal morbidity and mortality. A detailed description and precise image documentation of the damaged fetal structures have a fundamental forensic significance. Postnatal estimation of the time of hemorrhage using analysis of the cerebrospinal fluid and ultrasound findings (echogenicity of the lesions) is not always unified.

[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.