Necrotizing fasciitis after total abdominal hysterectomy: A case report.

RATIONALE: Necrotizing fasciitis is rapidly progressive infection with high mortality rate. This study aimed to summarize the clinical and pathological presentation of this case. PATIENT CONCERNS: A 46-year-old woman patient presented to our emergency department of an obstetric and gynecology clinic on the 8th day after total abdominal hysterectomy. The abdominal wall showed pronounced signs of inflammation. Abundant purulent content was oozing from the abdominal wound. DIAGNOSES: The patient underwent surgery. Areas of necrosis were observed on the skin around the wound, the subcutaneous fatty tissue was necrotic around the incision site, and the fascia was completely dehisced. INTERVENTIONS: Wound debridement and flap cutting of the anterior abdominal wall were performed. Metronidazole, ceftriaxone, and vancomycin were administered intravenously. A plastic surgeon suggested daily debridement and toileting of the wound in the operating room. Swabs of the abdominal cavity, abscess cavity, and abdominal wound were obtained, and Enterococcus faecalis was isolated. After the negativism of microbiological swabs, excochleation of granulation tissue was performed by a plastic surgeon. OUTCOMES: Nineteen days after the relaparotomy, the patient was discharged in good general condition with advice for further monitoring and therapy. LESSONS: Successful treatment of necrotizing fasciitis can be achieved through an initial diagnosis, adequate debridement, empirical broad-spectrum antibiotic coverage, and multidisciplinary treatment.

Diagnostic value of the apparent diffusion coefficient in differentiating malignant from benign endometrial lesions.

Introduction: Magnetic resonance imaging (MRI) with its innovative techniques, such as diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC), increases the diagnostic accuracy in distinguishing between malignant and benign lesions of the endometrium. The aim of the study was MRI differentiation between malignant and benign endometrial lesions and correlation with histopathological findings with a special emphasis on quantitative analysis. An additional aim was to correlate the ADC values and histological tumor grades. Methods: The prospective study included 119 female patients with or without vaginal bleeding and pathological values of endometrial thickness, who underwent MRI examinations. According to MRI reports the patients were divided into 45 suspicious malignant and 74 suspicious benign endometrial lesions. The radiological diagnosis was compared to the histopathological evaluation, which confirmed 37 malignant lesions while the rest were benign. Results: The mean ADC value for malignant lesions was 0.761 ± 0.13×10-3 mm2/s and for benign lesions was 1.318 ± 0.20×10-3 mm2/s. The ADC values for malignant lesions were expectedly lower than those of benign lesions (p<0.001). The ADC cut-off value was 1.007×10-3 mm2/s with a sensitivity of 100%, specificity of 92.7%, a positive predictive value of 60.3%, and a negative predictive value of 100%. In comparison with the histopathological findings, the sensitivity of MRI was 100%, specificity 90.2%, positive predictive value was 82.2%, and negative predictive value was 100%. Observing the histological grades 1, 2, and 3 of endometrial carcinoma, no statistically significant differences of mean ADC values were found. The mean ADC values for histological tumor grades 1,2 and 3 were 0.803 ± 0.13×10-3 mm2/s, 0.754 ± 0.12×10-3 mm2/s and 0.728 ± 0.13×10-3 mm2/s, respectively. Conclusion: DWI and ADC values represent clinically useful tools for the differentiation between malignant and benign endometrial lesions with high sensitivity and good specificity, but the results failed to demonstrate their usefulness in differentiating histological grades of endometrial cancer.

The phenomenon of pregnancy - a psychological view.

Pregnancy is a very specific and complex period in a woman's life. The accompanying changes are observed not only on the biological/physiological plane but also in her psychological and social functioning. Altered psychological functioning can occur from the very beginning to the end of pregnancy, including the postpartum period. During pregnancy, visible changes occur in the body's appearance, as well as in femininity, affections, and sexuality, whereas the woman's position and role are gaining new qualities. To a greater or lesser degree, every expectant mother experiences psychological am-bivalence, frequent mood changes from exhaustion to exaltation, emotional disturbances, and/or mixed anxiety-depressive disorder. In addition, pregnancy causes a number of specific apprehensions concerning the course and outcome, which makes the woman particularly vulnerable and requires adequate treatment, depending on the adaptive capacities of her personality. Furthermore, from a psychosocial aspect, pregnancy could be considered a specific highly emotional state, which may be a potent stressor. Perinatal maternal stress can lead to different complications that may have far-reaching consequences for both somatic and psychic functioning of the newborn. This review considers pregnancy as a complex psychological phenomenon and explores multiple changes in the woman's psychological functioning in both normal and psychologically complicated courses of pregnancy.

ALGORITHM OF OVULATION INDUCTION IN PATIENTS WITH POLYCISTIC OVARY SYNDROME.

INTRODUCTION: Polycystic ovary syndrome is the most frequent endocrine disturbance in the reproductive period of women's life and the most frequent cause of anovulatory infertility. Ovulation and pregnancy in patients having polycystic ovary syndrome may be a result of a wide range of therapeutic options, and the treatment assumes a gradual approach--from simple noninvasive to expensive and demanding procedures. MATERIAL AND METHODS: A systematic literature survey concerning the efficiency of particular ovulation induction methods in respect of the reproductive outcome was carried out with the aim of establishing the algorithm for ovulation induction in infertile patients having polycystic ovary syndrome. The search was confined to clinical investigations performed on human subjects, reported in English in the period from the beginning of 2010 to June of 2014. CONCLUSION: As a conclusion of this systematic survey of the efficiency of ovulation induction methods, which confirms and supplements the knowledge in this field, it is possible to form the algorithm for ovulation induction in infertile patients having polycystic ovary syndrome, consisting of the following subsequent steps: 1) modification of life style, 2) induction with clomiphene citrate 3) use of metformin, 4) use ofaromatase inhibitors, 5) application ofgonadotropins and laparoscopic ovarian drilling--as a second-line treatment, and 6) assisted reproductive techniques.

Comparison of the efficiency of clomiphene citrate and letrozole in combination with metformin in moderately obese clomiphene citrate-resistant polycystic ovarian syndrome patients.

INTRODUCTION: Polycystic ovary syndrome is the most common endocrinopathy in women of reproductive-age. Therapy for those who want to get pregnant involves ovulation induction using clomiphene citrate, metformin, letrozole and gonadotropins. OBJECTIVE: The aim of the study was to compare the efficacy of combinations of clomiphene citrate-metformin and letrozole-metformin in obese patients who are resistant to clomiphene citrate alone. METHODS: The investigation was conducted as a retrospective study involving 60 moderately obese patients with polycystic ovary syndrome. Thirty-one of them received the clomiphene citrate-metformin, and 29 letrozole-metformin therapy. Stimulation was carried out for the procedures of intrauterine insemination (IUI). RESULTS: The age of patients, duration of infertility, and body mass index in both groups were similar. There was statistically significant difference in the thickness of the endometrium in favor of the group having the letrozole-metformin therapy (8.9 ± 1.7 mm) compared with the group receiving the clomiphene citrate-metformin treatment (6.3 ± 1.3 mm). The number of follicles was not statistically significantly different. Pregnancy rate in the first cycle of IUI in the clomiphene citrate group was 6.4%, and 17.2% in the letrozole group, which also was not statistically different. After the third IUI cycle, the pregnancy rate was significantly higher in the letrozole group (20.6%), while in the clomiphene citrate group it was (9.6%). CONCLUSION: This retrospective study demonstrated the advantages of the use of letrozole over clomiphene citrate in combination with metformin in moderately obese patients with polycystic ovary syndrome who are resistant to stimulation with clomiphene citrate alone.

Obturator approach in the surgical treatment of stress urinary incontinence using tension-free transvaginal tape.

The study reviews the surgical treatment results of urinary stress incontinence in the group of 51 female patients, in whom the tension-free transvaginal tape was placed beneath the middle part of urethra using obturator approach during the period from 2005 to 2009. The method of surgery applied in all patients was obturator approach ("inside-out" method sec. de Leval), using a synthetic tension-free transvaginal prolen tape. After the sub-urethral tunnel had been created by scissors, the obturator membrane was perforated, then the placement of wing guides followed, through which helical needles with synthetic tape were brought to the skin. The following complications were observed in 8 (15.7%) patients: erosion of tape in 2 (3.9%), urine retention in 2 (3.9%), bleeding from the site of incision in 1 (1.9%) and transitory leg pain in 3 (5.8%) cases. Two years after the surgery, 43 (84.3%) patients were dry, 4 (7.8%) patients showed a significant improvement, while the recurrence was recorded in 4 (7.8%) operated patients.

[Physical therapy in the treatment of stress urinary incontinence].

INTRODUCTION: Stress urinary incontinence (SUI) is an involuntary release of urine through the urethra during the increase of abdominal pressure in the absence of m. detrusor contraction. The exercise of pelvic floor muscles is recommended as the first line of cure. It is the least invasive and the only method without any undesirable side effects, which leads to either improvement or complete cure of SUI in 80-85% of cases. OBJECTIVE: The aim of this study was to establish whether the strengthening of pelvic floor muscles using proprioceptive neural facilitation (PNF) spiral dynamic technique was more efficient in comparison to classical Kegel exercise. METHODS: The research was carried out at the Centre for Physical Medicine and Rehabilitation, Clinical Centre Kragujevac. Sixty-six female patients with the symptoms of SUI were monitored in the period of two years. Thirty-four patients did pelvic floor muscle exercises twice a day, in the morning and in the evening, with 15-20 contractions. Thirty-two patients used PNF spiral dynamic technique for strengthening pelvic floor muscles. The patients who used the spiral dynamic technique also did some exercises from the program; they exercised twice a day, in the morning and in the evening, following the prescribed schedule. Treatment outcome was assessed by measuring the pelvic floor muscles by a vaginal dynamometer. RESULTS: The values of the pelvic floor muscle force that were measured using the vaginal dynamometer in both examined groups (PNF spiral dynamic technique or Kegel exercise) were statistically significantly higher after the implemented exercise program (t-test; p=0.000). No statistically significant difference in pelvic floor muscle values was found between the patients who applied PNF spiral dynamic technique and those who did Kegel exercise either before or after the exercise (two-factor analysis of variance with repeated measurements, factor of exercise type; p=0.899). CONCLUSION: Strengthening of pelvic floor muscles by exercises results in a significant increase of pelvic floor muscle strength and reduction of SUI symptoms, regardless of the used exercise program, PNF spiral dynamic technique or Kegel exercise program.

Quality of life in women with urinary incontinence.

AIM: To determine the characteristics of urinary incontinence and its impact on the quality of life in adult women with urinary incontinence who presented to a tertiary care clinic of Vojvodina from September 2008 to May 2009 for treatment METHODS: We used a prospective case-control study. Cases were defined as patients (47) with urinary incontinence symptoms. Controls (50) were defined as patients without urinary incontinence who presented to a tertiary care gynecology clinic for other reasons. Both, cases and controls, completed two questionnaires recommended for the evaluation of symptoms, The Urinary Distress Inventory, and quality of life impact The Urinary Impact Questionnaire. RESULTS: There was a significant correlation between aging (r=0.614; p<0.01), body mass index (r=0.357; p<0.01) and menopause (r= -0.572; p<0.01) and urinary incontinence. All patients had symptoms of stress incontinence, 61.7% had urge incontinence symptoms, 21.3% voiding difficulty and 85.1% dysuria. Ninety-four patients believed that urinary incontinence impaired their quality of life: 50% of patients reported an impaired ability to do household activities, 59.1% avoided social activities, 70.4% reported an impaired ability to travel more than 30 minutes by car or bus, 88.6% avoided leisure activities, 45.5% of patients had impaired emotional health and 34% felt frustrated. CONCLUSIONS: The dominant type of urinary incontinence in more than half of the respondents was a mixed type, with moderate to very severe problems. Symptoms of urinary incontinence interfere with the performance of everyday household and social activities, causing the appearance of anxiety, depression and frustration, and in more than 50% of women leads to reduced quality of life.

[Most important etiologic factors in the development of genital prolapse].

INTRODUCTION: The incidence of genital prolapse depends on numerous factors. The contribution of race, gender and genetic factors is significant. However, additional factors of initiation, promotion and decomposition are necessary if a person with the genetic predisposition to genital prolapse begins to suffer from it. At least 50% of parous women are believed to suffer from genital prolapse of various degrees. Moreover, the prevalence of genital prolapse increases with age. The prevalence of genital prolapse is expected to be even higher in the future due to the extension of the lifespan of women worldwide. OBJECTIVE: The aim of this study was to determine the most common etiologic factors in the development of genital prolapse in the population of Serbia. METHODS: The study was conducted as prospective and included 50 women who underwent surgical treatment due to the problems caused by genital prolapse. RESULTS: Mean age of the women was 58.74 years. Twenty percent of the women had the menstrual cycle, while 80% were in menopause. Mean menopause period was 8.88 years. None of the women used hormone replacement therapy. Mean BMI was 27.395 kg/m2. Twenty-eight percent of the women were of normal weight, while 72% of the women were obese (42% were obese and 30% were severely obese). Ninety-eight percent of the women were parous, and mean parity was 2.08. Mean birth weight of neonates was 3682.77 g. Sixty-four percent of the women did physical labour and lifted heavy objects. CONCLUSION: Vaginal childbirth is one of the most important initiating factors. The most significant promoting factor is obesity and heavy labour. Ageing and entering menopause are the most important factors of decomposition as well as the occurrence of clinical manifestations of the pelvic floor dysfunction.

[Ultrasound detection of endometrial fluid in postmenopausal women]. / Ultrazvucna detekcija endometrijalne tecnosti kod zena u postmenopauzi.

UNLABELLED: The aim, of this prospective study was to estimate whether the presence of endometrial fluid detected by transvaginal ultrasound investigation was a marker for the pathological changes of the endometrium in postmenopausal women. MATERIAL AND METHODS: 128 postmenopausal women with uterine bleeding and 29 asymptomatic postmenopausal women underwent transvaginal ultrasound investigation, curettage and histopathological investigation of the curettage specimens. RESULTS: There were significantly more asymptomatic women with endometrial fluid collection was found (41,4%) than those with uterine bleeding (7,8%) (p<0,001). We found 4 cases of carcinoma of the endometrium, 4 with hyperplasia and 1 with polyp of the endometrium in women with uterine bleeding and endometrial fluid collection. In the asymptomatic group of women we found 1 case with polyp and 1 with carcinoma of the endometrium. In the presence of endometrial fluid collection the least thickness of the endometrium measured by transvaginal ultrasound was 12 mm in postmenopausal women with carcinoma of the endometrium, 7 mm in women with hyperplasia and 5 mm with polyp. No pathological changes were found below the above values. CONCLUSION: The presence of endometrial fluid detected by transvaginal ultrasonography is a good marker for pathological changes of the endometrium in postmenopausal women if the endometrial thickness is greater than 4 mm. If the endometrial thickness is 4 mm or less, the presence of endometrial fluid is not an indication for further invasive investigation of endometrial cavity, but we must eliminate possible presence of ednexal or cervical malignant disease in some patients.

[Ultrasound in screening of endometrial carcinoma in asymptomatic postmenopausal women].

INTRODUCTION: The aim of this prospective study was to investigate whether there was a significant difference in ultrasound detection of pathologic states of endometrium between asymptomatic postmenopausal women and postmenopausal women with uterine bleeding in whom the thickness of endometrium was greater than 3 mm at ultrasound examination. MATERIAL AND METHODS: The study included 128 postmenopausal women with uterine bleeding and 29 asymptomatic posmenopausal women who underwent gynecological examination, transvaginal ultrasound examination, fractional explorative curettage and histopathological examination of the endometrium. RESULTS: The results showed no statistically significant difference between the examined groups of women in relation to the detection of pathologic states of the endometrium (polyps, hyperplasias and carcinomas) as well as between individual pathologic states, although the research showed that the asymptomatic women were more frequently presented with well-differentiated carcinoma versus the medium-differentiated carcinoma in the symptomatic group of women. CONCLUSION: It can be concluded that the transvaginal ultrasound examination in postmenopausal women could be an adequate screening method for detection of endometrial carcinoma in early asymptomatic stage of the disease, whereas in the women with ultrasound finding of the thickened endometrium, the final diagnosis should be established by histopathological examination of the endometrium samples obtained by hysteroscopy, instead of previously used explorative curettage.

[Primary fallopian tube carcinoma].

INTRODUCTION: Primary fallopian tube carcinoma is extremely rare, making 0.3-1.6% of all female genital tract malignancies. Although the etymology of this tumor is unknown, it is suggested to be associated with chronic tubal inflammation, infertility, tuberculous salpingitis and tubal endometriosis. High parity is considered to be protective. Cytogenetic studies show the disease to be associated with over expression of p53, HER2/neu and c-myb. There is also some evidence that BRCA1 and BRCA2 mutations have a role in umorogeneis. CLINICAL FEATURES: The most prevailing symptoms with fallopian tube carcinoma are abdominal pain, abnormal vaginal discharge/bleeding and the most common finding is an adnexal mass. In many patients, fallopian tube carcinoma is asymptomatic. DIAGNOSIS: Due to its rarity, preoperative diagnosis of primary fallopian tube carcinoma is rarely made. It is usually misdiagnosed as ovarian carcinoma, tuboovarian abscess or ectopic pregnancy. Sonographic features of the tumor are non-specific and include the presence of a fluid-filled adnexal structure with a significant solid component, a sausage-shaped mass, a cystic mass with papillary projections within, a cystic mass with cog wheel appearance and an ovoid-shaped structure containing an incomplete separation and a highly vascular solid nodule. More than 80% of patients have elevated pretreatment serum CA-125 levels, which is useful in follow-up after the definite treatment. TREATMENT: The treatment approach is similar to that of ovarian carcinoma, and includes total abdominal hysterectomy and bilateral salpingo-oophorectomy. Staging is followed with chemotherapy.

[Abdominal sacrocolpopexy in surgical treatment of complete vaginal vault prolapse after hysterectomy].

INTRODUCTION: The vaginal vault prolapse after hysterectomy is a complex disorder, which can be associated with the prolapse of anterior or posterior vaginal wall or cystorectocele. The exact incidence is unknown, and is within the range from 1 - 43% of operated patients. In order to achieve the complete surgical reconstruction of the pelvic floor disorder, a surgeon must have good knowledge of normal anatomic relations of pelvic organs. MATERIAL AND METHODS: Twenty-nine women with the vaginal vault prolapse after hysterectomy were operated at Clinic for Gynecology and Obstetrics in Novi Sad during the period fiom 1995 - 2007. After standard preoperative procedures, positioning of the patient and inferior medial abdominal incision, the supportive graft made of non-resorptive materials was fixed to the vaginal fornix and sacral periost from the promontory to the level of S 3-4 vertebrae. RESULTS: The average age of the patients was 61.4 years. The following supportive materials were used: mersilen mesh (16), allograft made of m. rectus abdominis fascia (5), prolen (4), fascia lata strip (2) and common Silk sutures (2). Additional operations (Moschowitz Douglasoraphy, Kelly-Marion anterior vaginal repair, colpoperineoplasty and Burchcolposuspension) were performed in 20 (68.9%) patients. DISCUSSION: There were 7 (23.8%) postoperative complications. The erosion of mersilen mesh was detected in 2 (6.8%) patients, and recurrence of vaginal vault prolaps and cystorectocele in 3 (10.2%) patients. According to other authors, the erosion of synthetic materials occurs in about 3.4%, and recurrence of vaginal vault prolaps in 0-22% of operated patients. CONCLUSION: The complete vaginal vault prolaps after hysterectomy is a complex anatomic disorder which has a great impact on the life quality and significantly disturbs patient s psychosocial sphere. Surgical treatment involves abdominal or vaginal access and is planned individually for each patient.

[Accuracy of ultrasonic fetal weight estimation using head and abdominal circumference and femur length].

INTRODUCTION: Former investigations have shown that the accuracy of fetal weight estimation is significantly higher if several ultrasonic fetal parameters are measured, because the total body mass depends on the size of fetal head, abdominal circumference and femur length. The aim of this investigation was to establish the best regression model, that is a number of combinations of fetal parameters providing the most accurate fetal weight estimation in utero in our population. MATERIAL AND METHODS: This prospective study was carried out at the Gynecology and Obstetrics Clinic of the Clinical Center Novi Sad. It included 270 pregnant women with singleton pregnancies within 72 hours of delivery who underwent ultrasound measurements of the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL). RESULTS: In regard to fetal weight estimation formulas, the deviation was lowest using regression models that simultaneously analyzed four fetal parameters (0. 55%) with SD +/- 7.61%. In these models the estimates of fetal weights were within +/- 5% of actual birth weight in 48.89%, and within +/- 10% of actual birth weight in 81.48%. Good results were also obtained using AC, FL measurements (0.92% +/- 8.20) as well as using AC, HC, FL measurements (-1.45% +/- 7.81). In our sample the combination of AC and FL model gave better results in fetal weight estimation (0.92 +/- 8.20%) than the one using BPD and AC (2.97 +/- 8.83%). Furthermore, the model using parameters AC, HC and FL showed a lower error in accuracy (-1.45 +/- 7.81%) than the model using BPD, AC and FL (2.51 +/- 7.82%). CONCLUSION: This investigation has confirmed that the accuracy of fetal weight estimation increases with the number of measured ultrasonic fetal parameters. In our population the greatest accuracy was obtained using BPD, HC, AC and FL model. In cases when fast estimation of fetal weight is needed, AC, HC, FL model may be appropriate, but if fetal head circumference cannot be measured (amnion rupture and/or fetal head already in the pelvis) the AC, FL model should be used.

[Endometrial carcinoma--what are the protocols for?]. / Karcinom tela materice--cemu sluze protokoli?

INTRODUCTION: Endometrial cancer accounts for 10% of all malignant diseases affecting women in Western Europe. Women suffering from colonic, breast and ovarian cancer are at higher risk for developing endometrial carcinoma, which points to the fact that some women have a genetic predisposition for developing endometrial cancer. Precancerous conditions, adenomatous hyperplasias, are rarely diagnosed in our institutions. Treatment of endometrial cancer is individual, but surgeons are required to follow some treatment protocols. The aim of this study was to analyze how well treatment protocols are known and used MATERIAL AND METHODS: This study analyzed parameters of treatment of patients with endometrial cancer treated in two institutions treating oncologic patients in Novi Sad during a ten-year period (1991-2000). Results were obtained from patient records, specialist reports, surgery reports and history of disease. RESULTS: The investigation included 450 patients undergoing surgery for endometrial cancer. The average age was 62.5 years. Most patients underwent surgery in stage one (69.1%), two (14.57%), three (9.38%), zero (3.95%) and stage four (2.96%). Surgeries were performed by 16 surgeons, but none of them performed a standard treatment protocol completely. During the last 10 years 10% of patients did not undergo postoperative radiotherapy, due to outworn facilities and follow up of these patients by control of tumor markers was particularly important. DISCUSSION: The stage distribution of cancers is corresponding to that stated in literature. In regard to surgical approach and using treatment protocols, our surgeons stand behind their foreign colleagues. According to treatment standards of oncologic patients in developed countries, only specialised gynecologists and surgeons oncologists can perform operative treatment of oncologic patients. In regard to criteria in the leading countries of the world, 18 surgical gynecologists oncologists (23 the maximum) are sufficient for the territory of Serbia. CONCLUSION: Inadequate primary surgical treatment significantly increases the cost of therapy by late reoperations or additional postoperative treatment and has a negative effect on survival. In order to group patients and provide a well-educated staff with full work-time and adequate facilities, two (maximum three) institutions are sufficient at the territory of Vojvodina.