Caesarean section on request - a controversial request or the patient's right?

Caesarean section on request, a request that we have been encountering more and more recently. This can be interpreted as a primary caesarean section performed as a request of the mother without any relevant obstetrical or other medical indications in order to avoid vaginal delivery. The most common reason for mothers' requests for caesarean section is the fear of childbirth and the associated pain. Currently, medicine recognises the patient's right to actively participate in the choice of treatment procedures, including methods of delivery. We have accepted patients' claim for various aesthetic surgical interventions, in case they provide informed consent. The same principle should be maintained for caesarean sections on request.

A new perspective on Endometrial Carcinoma classification and management strategies in context of molecular subtypes.

Endometrial cancer is the most common gynecological cancer and the second most prevalent female malignancy in the developed world. It is typically diagnosed in postmenopausal women, presenting with the characteristic clinical symptom of uterine abnormal bleeding. In the past, only two histological types were considered. However, it has become increasingly evident that endometrial cancer is a clinically heterogeneous disease, and this heterogeneity is closely associated with the diversity of underlying molecular alterations. The Cancer Genome Atlas classification has significantly advanced the diagnosis, risk stratification, and management of endometrial cancer by categorizing it into four molecular subgroups, each characterized by distinct mutational burdens and copy number alterations.

Trophoblast stem cells, trophoblast invasion, and organoids - advancements in gynecology.

The human placenta serves as a vital barrier between the mother and the developing fetus during pregnancy. A defect in the early development of the placenta is associated with severe pregnancy disorders. Despite its complex development, various molecular processes control placental development, and the specialization of trophoblast cells is still not fully understood. One primary obstacle is the lack of suitable cell model systems. Traditional two-dimensional (2D) cell cultures fail to mimic in vivo conditions and do not capture the intricate intercellular interactions vital for studying placental development. However, three-dimensional (3D) organoid models derived from stem cells that replicate natural cell organization and architecture have greatly improved our understanding of trophoblast behavior and its medicinal applications. Organoids with relevant phenotypes provide a valuable platform to model both placental physiology and pathology, including the modeling of placental disorders. They hold great promise for personalized medicine, improved diagnostics, and the evaluation of pharmaceutical drug efficacy and safety. This article provides a concise overview of trophoblast stem cells, trophoblast invasion, and the evolving role of organoids in gynecology.

Birth plan - legal and medical aspects.

A birth plan is a document that defines mother's preferences and expectations regarding childbirth and early puerperium. The purpose of the birth plan is to establish communication about mother's birth wishes and to properly convey them to the health care providers. With increasing computerization of society, birth plan is currently the subject of heated debate. In this article, we present historical view of the birth plan, as well as current legislation regarding the birth plan, as we do not consider legal awareness of obstetricians to be sufficient at the moment. The purpose of this article is to appeal to the professional public so they have up-to-date information about the birth plan, especially in discussions with patients, but also during forensic procedures. The preservation of excellent perinatological results under our circumstances is only possible by providing professional, empathetic and very intimate health care in hospital institutions.

Changes in DNA methylation associated with a specific mode of delivery: a pilot study.

Background: The mode of delivery represents an epigenetic factor with potential to affect further development of the individual by multiple mechanisms. DNA methylation may be one of them, representing a major epigenetic mechanism involving direct chemical modification of the individual's DNA. This pilot study aims to examine whether a specific mode of delivery induces changes of DNA methylation by comparing the umbilical cord blood and peripheral blood of the newborns. Methods: Blood samples from infants born by vaginal delivery and caesarean section were analysed to prepare the Methylseq library according to NEBNext enzymatic Methyl-seq Methylation Library Preparation Kit with further generation of target-enriched DNA libraries using the Twist Human Methylome Panel. DNA methylation status was determined using Illumina next-generation sequencing (NGS). Results: We identified 168 differentially methylated regions in umbilical cord blood samples and 157 regions in peripheral blood samples. These were associated with 59 common biological, metabolic and signalling pathways for umbilical cord and peripheral blood samples. Conclusion: Caesarean section is likely to represent an important epigenetic factor with the potential to induce changes in the genome that could play an important role in development of a broad spectrum of disorders. Our results could contribute to the elucidation of how epigenetic factors, such as a specific mode of delivery, could have adverse impact on health of an individual later in their life.

Home births as a "right" of female patients in the context of medicine, legislation and court jurisprudence.

Currently, in the Czech Republic and Slovakia, more and more women prefer a planned home birth to a hospital birth, despite the fact that the hospital provides a safe environment for laboring women, thanks to the possibility to intervene at any time in case of complications. These women consider childbirth a natural process, while obstetric care is often considered unnecessary. According to the World Health Organization, birth can only be defined as physiological after birth. Even though women can give birth without medical assistance, it is not possible to identify in advance the mothers and newborns who will need some kind of intervention during childbirth. Although a planned home birth is associated with fewer maternal interventions and the probability of a spontaneous vaginal birth, compared to a planned hospital birth, the risk of neonatal death is two- to three-times higher.

Effect of umbilical cord drainage after spontaneous delivery in the third stage of labor.

Umbilical cord drainage involves releasing the cord clam from the umbilical cord after separation of the newborn from the maternal end of the umbilical cord. Consequently, there is emptying of blood from the placenta. This procedure is part of the active management of the third stage of labor (TSL). OBJECTIVE: This study is intended to provide knowledge about the duration of TSL and the risk of retention of the placenta using umbilical cord drainage and the no-drainage procedure. MATERIALS AND METHODS: A prospective randomized study of the management of the third stage of labor in 600 patients. The patients were equally divided into two groups with umbilical cord drainage (300) and without umbilical cord drainage (300). TSL was actively managed by FIGO (the International Federation of Gynecology and Obstetrics) recommendations. We monitored the duration of TSL and retention of the placenta after a 30 min period. RESULTS: The mean duration of TSLwas 6.8 ± 0.4 min in the drainage group and 11.6 ± 0.8 min in the control group. We conclude that umbilical cord drainage significantly shortens the duration of TSL (P = 0.026) as well as reduces the risk of placental retention. In a group where we use the drainage of the umbilical cord, placental retention 30 min after delivery of the fetus occurred in four cases while the second set occurred in 14 cases (RR 3.62; 95% CI 1.18-11.14). CONCLUSION: We assume that during umbilical cord drainage, the collapse of thin-walled uteroplacental vessels occurs earlier causing bleeding from these vessels between the placenta and the uterine wall, and therefore, earlier separation of the placenta occurs. Of course, the drainage of the umbilical cord is only one step in the algorithm of active management at the third stage of labor according to FIGO.

Epidermolysis in a newborn of a mother affected by covid-19 in the 3rd trimester of pregnancy.

Covid-19, caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently a pandemic. Although this infection primarily presents with respiratory symptoms, the number of reported extrapulmonary manifestations, including dermatological, is also increasing. A group of pregnant women is particularly susceptible to respiratory diseases, but with regard to covid-19, there is still limited data on the course of infection in pregnancy in relation to the possibility of vertical transmission. We present the case of a 30-year-old unvaccinated patient with a history of overcoming covid-19 infections in the 7th month of pregnancy, and with persistent skin lesions. The patient gave birth to a mature newborn with epidermolytic lesions on a bullous base. In the differential dia-gnostic process, Staphylococcal scalded skin syndrome and epidermolysis bullosa were ruled out in the newborn. Considering the clinical findings and epidemiological history of the mother, we assume a possible vertical transmission of covid-19 with skin manifestation of the disease in the newborn.

Outcome of a patient with Herlyn-Werner-Wunderlich syndrome treated with Balloon septostomy - pre- and postsurgical ultrasound findings.

Herlyn-Werner-Wunderlich syndrome is an unusual congenital anomaly defined by a triad of congenital defects of the female urogenital tract - homolateral renal agenesis, uterus duplex and obstructed hemi-hematometrocolpos whose etiology remains still unclear. Pelvic pain, dysmenorrhea and palpable mass due to the hematocolpos or hematometra are the most common clinical symptoms. Endometriosis is considered to be a prevalent finding in these young patients possibly explaining the pathophysiological mechanism of endometriosis as the result of retrograde menstruation. Early diagnosis and subsequent treatment are important to prevent the development of severe complications. In general, clinical and reproductive outcomes after drainage of the hematometrocolpos are reported to be satisfactory. A 13-year-old patient presented with pelvic pain and was diagnosed with OHVIRA syndrome treated with Balloon septostomy.

Interaction between Mesenchymal Stem Cells and the Immune System in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disease that causes damage to joints. This review focuses on the possibility of influencing the disease through immunomodulation by mesenchymal stem cells (MSCs). There is an occurrence of rheumatoid factor and RA-specific autoantibodies to citrullinated proteins in most patients. Citrulline proteins have been identified in the joints of RA patients, and are considered to be the most suitable candidates for the stimulation of anti-citrulline protein antibodies production. Fibroblast-like proliferating active synoviocytes actively promote inflammation and destruction in the RA joint, in association with pro-inflammatory cells. The inflammatory process may be suppressed by MSCs, which are a population of adherent cells with the following characteristic phenotype: CD105+, CD73+, CD90+, CD45-, CD34- and HLA DR-. Following the stimulation process, MSCs are capable of immunomodulatory action through the release of bioactive molecules, as well as direct contact with the cells of the immune system. Furthermore, MSCs show the ability to suppress natural killer cell activation and dendritic cells maturation, inhibit T cell proliferation and function, and induce T regulatory cell formation. MSCs produce factors that suppress inflammatory processes, such as PGE2, TGF-ß, HLA-G5, IDO, and IL-10. These properties suggest that MSCs may affect and suppress the excessive inflammation that occurs in RA. The effect of MSCs on rheumatoid arthritis has been proven to be a suitable alternative treatment thanks to successful experiments and clinical studies.

In Vitro Model of Human Trophoblast in Early Placentation.

The complex process of placental implantation and development affects trophoblast progenitors and uterine cells through the regulation of transcription factors, cytokines, adhesion receptors and their ligands. Differentiation of trophoblast precursors in the trophectoderm of early ontogenesis, caused by the transcription factors, such as CDX2, TEAD4, Eomes and GATA3, leads to the formation of cytotrophoblast and syncytiotrophoblast populations. The molecular mechanisms involved in placental formation inside the human body along with the specification and differentiation of trophoblast cell lines are, mostly due to the lack of suitable cell models, not sufficiently elucidated. This review is an evaluation of current technologies, which are used to study the behavior of human trophoblasts and other placental cells, as well as their ability to represent physiological conditions both in vivo and in vitro. An in vitro 3D model with a characteristic phenotype is of great benefit for the study of placental physiology. At the same time, it provides great support for future modeling of placental disease.

Fetal neck giant hemangioma associated with postnatal arising Kasabach-Merritt syndrome.

We report a prenatal ultrasound dia-gnosis of giant neck hemangioma at 30+1 weeks in a fetus resulting in the postnatal development of Kasabach-Merritt syndrome. Ultrasound scan revealed a large isoechoic mass occupying the whole neck, infiltrating the nasopharyngeal cavity, tongue, lower lip and mandible. Complex sonographic visualization with 2D and 4D was helpful in the process of parental counseling.

Religion Affects Future Female Doctors' Approach to HPV Vaccination in Czech and Slovak Republics.

The objective of this study is to summarize the factors, including religion, affecting an individual's decision to get vaccinated or reject vaccination. Anonymous questionnaire-based electronic study is conducted in all faculties of medicine in Czech and Slovak republics. One thousand four hundred and six (1406) questionnaires were analyzed. Responders not practicing any religion received vaccination more often and would recommend vaccination more often. Catholic religion was the most important demographic factor affecting the rate of vaccination. In the group of Catholic female students, 21.9% were vaccinated. In the group of non-Catholic female students, 55.5% were vaccinated. In conclusion, female medical students' approach to vaccination depends, among other factors, on their individual beliefs.

Comparison of opinions of Slovak and Czech female medical students on HPV vaccination.

OBJECTIVES: This study aims to identify the differences in the use of HPV vaccination between female medical students in the Czech and Slovak Republics and their possible causes. METHODS: We performed a cross-sectional survey among female students of general medicine in all faculties of medicine in the Czech and Slovak Republics. RESULTS: We obtained 630 questionnaires from the Czech Republic and 776 questionnaires from the Slovak Republic. In the Czech Republic, 65.4% of female medical students underwent HPV vaccination, while in the Slovak Republic, the figure was 21.1%. In the Czech Republic, residency and religion of students did not influence their rate of vaccination. However, in the Slovak Republic, village residency with less than 5,000 inhabitants lowered the probability of vaccination with OR = 0.56 (95% CI: 0.38-0.84), and the Catholic religion lowered the probability of vaccination with OR = 0.40 (95% CI: 0.28-0.57). Czech students were informed about the possibility of vaccination by a paediatrician in 55.7% of cases, while the figure for Slovak students was 26.8%. In the Czech Republic, 75.7% of students participated in regular cervical oncologic screening, while in the Slovak Republic, the figure was 57.7%. Vaccination of relatives would be recommended by 86.5% and 80.5% of Czech and Slovak students, respectively. CONCLUSIONS: The adoption of an oncologic prevention programme and the more extensive propagation by paediatricians are probably the medical reasons for the higher HPV vaccination among Czech students. Demographic factors - village residency and religion - are also important.

Association between deficient cesarean delivery scar and cesarean scar syndrome.

INTRODUCTION: The aim of our study was to compare long-term morbidity after elective and emergency cesarean delivery (CD). METHODS: A prospective cohort study was conducted in 200 women delivered by CD. Ultrasound examinations were performed transvaginally at 6 weeks and 18 months after CD. Clinical data were collected at the time of CD and after 18 months. RESULTS: In the group of 200 women, 29% underwent emergency and 71% elective CD. Then, 6 weeks and 18 months after CD, a severe scar defect was present in 7% and 5%, respectively (P = .4). After 18 months of CD, 17% (34/200) of women had evidence of adhesions of the vesicouterine pouch. Severe CD scar defects were significant predictors for adhesion formation in vesicouterine pouch (OR 3.14, 95% CI, 1.54-4.74), pelvic pain (OR 1.68, 95% CI, 0.22-3.14), dysmenorrhea (OR 2.12, 95% CI, 0.74-3.50), and dyspareunia (OR 1.38, 95% CI, 0.09-2.67). Uterine scar defects detected at 6 weeks after elective CD were detectable at 18 months in only 40% of cases, whereas uterine scar defects after emergency CD were still detectable in 87% of cases. CONCLUSION: Uterine scar defects are more frequent at 18 weeks after emergency CD, than after elective CD (40% vs 87%). Women with severe scar defects have higher risk of adhesion formation, dysmenorrhea, dyspareunia, and chronic pelvic pain.

Genistein: a promising molecule modulating tumour growth and wound healing?

Although it has been shown that oestrogen replacement therapy is able to improve wound healing, several side effects of this replacement therapy have precluded its common use in clinical practice. On the other hand, the phytoestrogen genistein (the selective oestrogen receptor modulator belonging to the group of isoflavones) has been introduced into several clinical trials to improve cancer treatment efficiency and experiments suggest its positive effect on wound healing. The main mechanisms of action, which have been elucidated so far, include induction of apoptosis, cell cycle arrest, inhibition of angiogenesis and tyrosine kinase activity as well as cancer chemoprevention and reduction of climacteric symptoms. Unfortunately, all underlying mechanism in the modulation of biological processes involved in wound healing and tumour growth are not yet fully understood. Therefore, the present review summarizes the effects of genistein on biological processes in different wound healing models and selected tumours. Key words: genistein • tissue repair and regeneration • carcinoma • skin.

Genistein Improves Skin Flap Viability in Rats: A Preliminary In Vivo and In Vitro Investigation.

Selective estrogen receptor modulators (SERMs) have been developed to achieve beneficial effects of estrogens while minimizing their side effects. In this context, we decided to evaluate the protective effect of genistein, a natural SERM, on skin flap viability in rats and in a series of in vitro experiments on endothelial cells (migration, proliferation, antioxidant properties, and gene expression profiling following genistein treatment). Our results showed that administration of genistein increased skin flap viability, but importantly, the difference is only significant when treatment is started 3 days prior the flap surgery. Based on our in vitro experiments, it may be hypothesized that the underlying mechanism may rather by mediated by increasing SOD activity and Bcl-2 expression. The gene expression profiling further revealed 9 up-regulated genes (angiogenesis/inflammation promoting: CTGF, CXCL5, IL-6, ITGB3, MMP-14, and VEGF-A; angiogenesis inhibiting: COL18A1, TIMP-2, and TIMP-3). In conclusion, we observed a protective effect of genistein on skin flap viability which could be potentially applied in plastic surgery to women undergoing a reconstructive and/or plastic intervention. Nevertheless, further research is needed to explain the exact underlying mechanism and to find the optimal treatment protocol.

Should open excisions and sutured incisions be treated differently? A review and meta-analysis of animal wound models following low-level laser therapy.

Although low-level laser therapy (LLLT) was discovered already in the 1960s of the twentieth century, it took almost 40 years to be widely used in clinical dermatology/surgery. It has been demonstrated that LLLT is able to increase collagen production/wound stiffness and/or improve wound contraction. In this review, we investigated whether open and sutured wounds should be treated with different LLLT parameters. A PubMed search was performed to identify controlled studies with LLLT applied to wounded animals (sutured incisions-tensile strength measurement and open excisions-area measurement). Final score random effects meta-analyses were conducted. Nineteen studies were included. The overall result of the tensile strength analysis (eight studies) was significantly in favor of LLLT (SMD = 1.06, 95% CI 0.66-1.46), and better results were seen with 30-79 mW/cm2 infrared laser (SMD = 1.44, 95% CI 0.67-2.21) and 139-281 mW/cm2 red laser (SMD = 1.52, 95% CI 0.54-2.49). The overall result of the wound contraction analysis (11 studies) was significantly in favor of LLLT (SMD = 0.99, 95% CI 0.38-1.59), and the best results were seen with 53-300 mW/cm2 infrared laser (SMD = 1.18, 95% CI 0.41-1.94) and 25-90 mW/cm2 red laser (SMD = 1.6, 95% CI 0.27-2.93). Whereas 1-15 mW/cm2 red laser had a moderately positive effect on sutured wounds, 2-4 mW/cm2 red laser did not accelerate healing of open wounds. LLLT appears effective in the treatment of sutured and open wounds. Statistical heterogeneity indicates that the tensile strength development of sutured wounds is more dependent on laser power density compared to the contraction rate of open wounds.

Outcomes of Laparoscopic Treatment in Women with Cesarean Scar Syndrome.

BACKGROUND The aim of this study was to evaluate the outcomes of laparoscopic treatment of women with severe defect of a Cesarean section (CS) scar and Cesarean scar syndrome. MATERIAL AND METHODS A prospective longitudinal study was conducted in 11 women who were treated for Cesarean scar syndrome. Ultrasound examinations were performed transvaginally 1 day before surgery and 6 months after laparoscopy in all women. Clinical data were registered 1 day before laparoscopy and 6 months after laparoscopy. RESULTS Of these 11 women, total dehiscence of the CS scar was present in 72.7% (8/11) of the women. Before laparoscopy, all 11 women had severe defect of the CS scar (DRC ≤0.25); however, 6 months after laparoscopy, 81.8% (9/11) of women still had severe defect of the CS scar. Mean thickness of the CS scar, measured 1 day before and 6 months after laparoscopy in all 11 women, was 0.3±0.4 mm and 1.3±1.0 mm, respectively. Accordingly, no significant differences were observed in the mean CS scar thickness (p=0.101). After laparoscopy, 63.6% (7/11) of women were fully asymptomatic, and among the remaining 4, the most common complications were dyspareunia in 36.4% (4/11, p=0.005), pelvic pain in 27.3% (3/11, p=0.014), and dysmenorrhea in 18.2% (2/11, p=0.01), and best results after laparoscopy were achieved for postmenstrual spotting in 18.2% (2/11, p<0.001). CONCLUSIONS Improvement of women's health after laparoscopy does not necessarily mean improvement of CS scar sonomorphology. Surgery should be offered only to women with symptoms of the Cesarean scar syndrome.