Menopausal hormone therapy in questions and answers - a manual for physicians of various specialties.

This manual has been prepared by the Expert Team of the Polish Menopause and Andropause Society for physicians representing various medical specialties who see patients with menopausal symptoms in their daily practice. In order to make the manual as practical as possible, the current state of knowledge on menopausal hormone therapy (MHT) is presented in the form of questions and answers. They address issues which are essential for initiating and managing MHT based on the most up-to-date treatment algorithms and, at the same time, in line with the old maxim "primum non nocere".

An alternative approach to gynecological wound healing.

An 89-year-old woman was reffered to our Clinic with vulvar cancer. She also suffered from obesity [with body mass index (BMI) 35 kg/m2], persistent hypertension, diabetes mellitus type 2 treated with oral medications. In 2015 she underwent a surgery due to endometrial carcinoma. Total abdominal hysterectomy with bilateral salphingoophorectomy, omentectomy and pelvical node dissection was performed (histopathology revealed adenocarcinoma serosum G2; FIGO stage Ib). In January 2016 after vulvar ulceration biopsy plano-epithelial squamous vulvar cancer was diagnosed. She was referred to surgery. She has undergone an operation in October 2016. She was admitted to gynaecological unit at our institution. Physical examination revealed mutilated vulva with excised labia major, labia minor, and narrowing of vaginal orifice. The right side shown tumor 2.5 cm in diameter, with slough area and no deep infiltration and satellital nodule on the left labia majora 1cm in diameter. The cervix, vaginal wall, rectum and anus appeared normal. There were no enlarged lymph nodes at the inguinal area.

Short cervix in twin pregnancies: current state of knowledge and the proposed scheme of treatment.

Short cervical length (SCL) should be defined as cervical length (CL) less than 25 mm between 18 and 22 weeks of gestation. This definition of SCL is fully applicable for singleton pregnancies but is not entirely correct for twin pregnancies. So far there are no explicit guidelines on the treatment of twin pregnancy with SCL. The use of progesterone in the treatment of SCL and preterm birth (PTB) prophylaxis is one of the interventions recommended by the Polish Ministry of Health for cervical shortening in singleton pregnancies. In twin pregnancies attention should be paid to the potential benefits of using vaginal progesterone in reduction of neonatal mortality and incidence of neonatal complications in a group of patients with twin pregnancies and CL less than 25 mm or below the 10th percentile for the gestational age, measured between 18 and 22 weeks of gestation. It is still difficult to identify the benefits of using pessaries in the prevention of PTB in twin pregnancies. The usage of pessaries appears to be beneficial only in selected subpopulations of patients with asymptomatic CL less than 25 mm or 10th percentile for gestational age. The use of cervical cerclage in PTB prevention in twin pregnancies is limited to cases where the external cervical dilation is >1 cm and.

Ultrasound guided balloon catheterisation: a new method of fetal lower urinary tract obstruction management.

OBJECTIVES: Fetal lower urinary tract obstruction (LUTO), most often associated with presence of posterior urethral valves, poses high risk of perinatal mortality or postnatal renal failure. Looking for a method of causative treatment we have devel-oped a technique of fetal urethroplasty with a coronary angioplasty balloon catheter inserted under an ultrasonographic guidance via an 18-gauge needle introduced transabdominally to fetal bladder. MATERIAL AND METHODS: We have used this procedure in three women with singleton pregnancies (two primiparas and one multipara, 32-35 years of age), diagnosed with fetal megacystis at 12-16 weeks of gestation. Urethral catheterization was carried out at 16-18 weeks and an unobstructed urine flow was achieved in all three cases immediately after the procedure, followed by a resolution of megacystis and normalization of amniotic fluid volume. RESULTS: In all three cases, the post-procedure period was uneventful. In the first two fetuses, amniotic fluid volume re-mained normal until 30 weeks of gestation when a gradual development of oligohydramnios and some signs of renal cystic dysplasia were observed. Nevertheless, both pregnancies were continued till term (37 and 39 weeks, respectively) and two boys without signs of pulmonary hypoplasia were delivered. The third patient is currently 25 weeks pregnant; volume of amniotic fluid in her fetus is normal and no signs of urinary flow obstruction or renal dysplasia have been recorded thus far. CONCLUSIONS: Although some technical aspects of the procedure still need to be established, it seems worth consideration as a form of potentially least traumatic intrauterine intervention in fetuses with lower urinary tract obstruction.

Early vesico-amniotic shunting - does it change the prognosis in fetal lower urinary tract obstruction diagnosed in the first trimester?

OBJECTIVES: The aim of the study was to assess the outcome of vesico-amniotic shunting performed before 16 weeks of pregnancy in fetuses with severe megacystis diagnosed in the first trimester of pregnancy. MATERIAL AND METHODS: Between January 2008 and October 2012 severe megacystis with the bladder length > 15 mm was diagnosed in 17 fetuses. The procedure of early vesico-amniotic shunting (VAS) was offered to 8 patients with presumably isolated LUTO. The procedure of VAS was performed in 6 fetuses. Before the intervention one or two procedures of vesicocentesis and urine analysis were performed. RESULTS: In all treated cases shunts provided urinary tract decompression. All babies were born prematurely, 2 of them died due to premaurity, 3 of them survived and have normal renal function at the age of 5-6 years. In 4/5 children accompanying malformations were later diagnosed, in 1 born prematurely neonate necropsy was not performed. CONCLUSIONS: Our results suggest that early vesico-amniotic shunting in fetal LUTO is feasible and may potentially prevent not only pulmonary hypoplasia but also renal insufficiency. However, the rationale of the procedure needs further investigation due to a high risk of long-term morbidity and co-existing malformations in children Before offering the therapy detailed counseling of the parents about the possible pros and cons of the therapy is necessary.

Ten years of anti-HPV vaccinations: what do we know?

Human papillomavirus (HPV) is one of the most important carcinogens in humans. Vaccines against HPV are now considered the first anti-cancer vaccinations. Since 2007, in many developed countries, there have been recommendations present for preventive vaccines against HPV. At present, the degree of implementation of these recommendations depends on a number of country-specific factors such as the health care system organization or the ways of funding. HPV vaccines are primarily to prevent the development of cervical cancer and other genital cancers. Therefore, only their long-term effectiveness can be measured, when a correspondingly large cohort of vaccinated teenagers reaches the age of the greatest incidence of these cancers. However, great care should be taken in assessing the results of vaccinations due to the possibility of misinterpretation and possible erroneous data. Undoubtedly, teenagers are the target population of HPV vaccines. However, vaccinating young sexually active women is also justified from an individual point of view. A 9-valent vaccine has been registered in the USA and in Europe - including Poland - as one of the three preventive vaccines. It is recommended to vaccinate women between 13 and 26 and men between 13 and 21, previously unvaccinated. It is also recommended to vaccinate men aged 26 years or less who have sexual relations with other men and people with reduced immunity, including HIV-positive people who have not been vaccinated previously.

[PREVFNAIT prevention of foetal/neonatal alloimmune thrombocytopenia (FNAIT) in Polish foetuses and newborns--the PREVFNAIT program]. / Zapobieganie alloimmunologicznej maloplytkowosci plodów i noworodków (AIMPN) w Polsce--program PREVFNAIT.

The scientific goals related to the grant include 1) estimation of FNAIT prevalence in Poland and 2) search for biomarkers to predict the risk of the antibody production and severity of fetal thrombocytopenia. Fetal/Neonatal Alloimmune Thrombocytopenia (FNAIT) is caused by destruction of fetal blood platelets due to maternal antibodies. This condition, which most commonly results from incompatibility between the mother and the fetus for the Human Platelet Antigen-1a (HPA-1a), may lead to intracranial hemorrhage, damage of the central nervous system (CNS) and even death of the fetus or the newborn. It can be the cause of strokes in term newborns. FNAIT is usually attributed to the presence of anti-HPA-1a antibodies. Its incidence rate is estimated at approximately 1/1000-2000 live births. In the absence of a screening program, it is usually diagnosed after birth of a child with symptoms of thrombocytopenia or CNS hemorrhage. Monitoring of antibody production and thrombocytopenia treatment to effectively minimize the risk of stroke are therefore launched only at the next pregnancy. Testing indications are broader to include fetal ultrasound for symptoms of stroke to the CNS, ventricular enlargement or hydrocephalus, and obstetric failure. Diagnostic process is also recommended prior to the planned cordocentesis, in vitro fertilization and in sisters of mothers with children with FNAIT history. HPA-1a testing remains the best method for diagnosing pregnancies at risk. The detection frequency for FNAIT in Poland remains low. Therefore, the Institute of Hematology and Transfusion Medicine (IHTM) will have performed such HPA-1a antigen testing in 30 000 Polish women within the framework of the PREVFNAIT program by March 2016. HPA-1a negative women (2% of the population) are a risk group for production of anti- HPA-1a antibodies responsible for FNAIT therefore all of them will be monitored for the presence and activity of anti-HPA-1a antibodies. Such testing will be performed free of charge for the women.

[Fetal cardiac interventions - are we ready for them?]. / Interwencyjne zabiegi kardiologiczne u plodów - czy jestesmy do nich przygotowani?

OBJECTIVE: The aim of the study was to analyze types and methods of intrauterine fetal cardiac interventions performed between June 2011 and December 2013, and to assess the perinatal management of the neonates. METHODS: The program was developed after analysis of the available literature, practical individual training in Linz, Austria, and simulation of the procedure in a dissecting-room. The rules for anesthesia in pregnant women and their fetuses were developed. The interventions were performed in fetuses with critical cardiac defects, in the operating room, under ultrasonographic control. The protocol was approved by the Local Bioethics Committee at the Centre of Postgraduate Medical Education. MATERIAL: We included fetuses with critical aortic stenosis (n=29), critical pulmonary stenosis (n=2), and closed or extremely restricted foramen ovale (n=7). Between June 2011 and December 2013, the team comprised of JD, MD and AK conducted 42 interventions in 35 fetuses, including 32 balloon aortic valvuloplasties (in 29 fetuses), 2 pulmonary valvuloplasties, 4 balloon atrial septostomies and 4 atrial septal stent placement. Three fetuses required both, aortic valvuloplasty and fenestration of the atrial septum. RESULTS: Out of the 42 procedures, 41 (97%) were technically successful. We recorded 3 cases of fetal demise associated with the intervention. We modulated the protocol of anesthesia given to pregnant women, switching from general to local anesthesia with intravenous sedation. We always provided additional fetal anesthesia with fentanyl and atracurium via the umbilical vein. CONCLUSIONS: Based on our 2.5-year experience, it seems safe to conclude that all types of fetal cardiac interventions may be successfully conducted at Polish centers. The procedures are safe for the pregnant women and improve fetal status. Most of the neonates treated prenatally were referred in good general condition to a tertiary pediatric cardiology and cardiac surgery center

Recommended management of Toxoplasma gondii infection in pregnant women and their children.

Aforesaid recommendations for the management of T.gondii infection, elaborated by the group of experts, are intended for physicians of various specialties in order to standardize and facilitate diagnostic and therapeutic management. Early diagnosis of congenital toxoplasmosis, both symptomatic and asymptomatic, in neonatal period, initiation of adequate treatment and long-term, multispecialist monitoring, including multi-organ rehabilitation of children may prevent or reduce the complications of congenital toxoplasmosis. Health education, whose role is often underestimated, should be targeted mainly on girls and women at reproductive age as to prevent from infection during pregnancy.

[The CHOICE study (Contraceptive Health Research Of Informed Choice Experience)--an educational research program for Polish women planning combined hormonal contraceptives use]. / CHOICE (Contraceptive Health Research of Informed Choice Experience)--edukacyjny program badawczy dla kobiet planujacych stosowanie zlozonej antykoncepcji hormonalnej w Polsce.

OBJECTIVES: The aim of the study was to develop an optimal educational model for contraceptive counseling, to analyze conditions influencing choice of hormonal contraception, to study patients' opinions on present, planned and proposed contraceptive methods and to link these data with socioeconomic and demographic conditions. MATERIALS AND METHODS: One thousand eight hundred fifty women (mean age 26.8 +/- 5.9 yrs) willing to use hormonal contraception were presented with essential information on combined hormonal contraception and asked to fill the anonymous questionnaire investigating factors influencing contraceptive choice and patients' opinion on alternative forms of birth regulation. The study was conducted in selected 185 centers in Poland and was a part of a larger survey (CHOICE) conducted on 11 216 women in Europe and Israel. RESULTS: Majority of the studied women were in stable relationship (85,5%), had higher or incomplete higher education (54.8%) and permanent job (54%). The purpose of the visit was to start/change contraception (64.2%), a routine gynecologic check-up (36.7%) or the need for a prescription for the continued contraceptive medication (18.7%). The most commonly used contraceptive methods were oral contraceptive pills (OCP 38.7%) and condom (24.9%). Majority of women highly valued contraceptive counseling and more than 90% were eager to get familiarized with information leaflets. Before the counseling majority of subjects stated that were convinced to use OCP (52.7%; major advantages named: easy to use, favorable bleeding profile, amelioration of menstrual discomfort, comfortable, discrete) and contraceptive patch (22%; major advantages named: applied once a week, comfortable, simple, low risk for noncompliance, favorable bleeding profile). After the counseling there was an increase in proportion of women interested in contraceptive hormonal ring (by 19%; major advantages named: applied once a month, comfortable, very low risk for noncompliance, high efficacy and positive recommendation from a physician). In 58 women no hormonal contraception was recommended, predominantly due to medical contraindications. CONCLUSIONS: Appropriate patient counseling on all forms of combined hormonal contraception, with special attention paid to benefits and safety issues, suited to women's expectations and education is fundamental for the selection of an optimal birth control method.

[Oral combined hormonal contraception containing nomegestrol acetate and 17beta-oestradiol--the statement of Polish Gynecological Society Experts Group]. / Stanowisko Ekspertów Polskiego Towarzystwa Ginekologicznego. Doustna zlozona antykoncepcja hormonalna oparta na octanie nomegestrolu i 17beta-estradiolu.

Nomegestrol acetate (NOMAC) combined with E2 (Zoely) is a monophasic oral contraceptive (OC) which safety and efficacy was confirmed in a number of level I evidence clinical trials. Zoely is highly effective OC, especially in overweight and obese patients, with good cycle control, safe and well tolerated. NOMAC/E2 combination causes no or minimal weight gain and is characterized by minimal influence on bone mineral density or blood pressure and presence of acne. Moreover lipids profile, carbohydrates metabolism, haemostasis and endocrine glands functioning were not affected. High tolerance and acceptance of NOMAC/E2 combination by women, low adverse event profile, fast recovery of ovarian activity and ovulation is a reasonable treatment tool in everyday practice.

[The first successful fetal aortic balloon valvuloplasty in Poland]. / Pierwsza w Polsce skuteczna przezskórna plastyka balonowa zastawki aortalnej u plodu.

Prenatal aortic valvuloplasty is performed only in few perinatal centers in the world. Critical aortic stenosis which can lead to hypoplastic left heart syndrome or severe fetal heart failure with nonimmune hydrops is an indication for this procedure. Prenatal intervention can change the natural course of the disease. Authors present the first successful fetal balloon aortic valvuloplasty in Poland. It was performed in a 29-week fetus with critical aortic stenosis, severe impairment of left ventricular function, heart failure and fetal hydrops. After successful intervention, without any complications, left ventricular function and fetal condition improved gradually Effective fetal intervention was possible after few months of preparation and building a team of specialists. This is the first successful fetal cardiac intervention in Poland, which opens the way to the new era of fetal cardiology and hopefully will lead to improve results in children with this critical heart defect.

Fetal Cardiac Interventions-Polish Experience from "Zero" to the Third World Largest Program.

This article presents the technical aspects of the Polish fetal cardiac interventions (FCI) program, including preparation of the team and modifications in the technique of the procedure that aim to increase its safety for the mother and the fetus. Over 9 years, 128 FCI in 113 fetuses have been performed: 94 balloon aortic valvuloplasties (fBAV), 14 balloon atrioseptoplasties (fBAS) with stent (BAS+), 5 balloon atrioseptoplasties without stent placement (BAS-), and 15 fetal pulmonary valvuloplasties (fBPS). The technical success rate ranged from 80% (BAS-) to 89% (fBAV), while the procedure-related death rate (defined as death within 72 hours following the procedure) ranged from 7% (fBAV and fBPV) to 20% (BAS). There were 98 live births after all FCI (3 pregnancies continue). Median gestational age at delivery was 39 weeks in our center and 38 weeks in other centers.

[Large uterine leiomyoma in pregnancy--case report]. / Olbrzymi miesniak macicy u ciezarnej --opis przypadku.

This is a case report of a successful pregnancy outcome in a 36-year-old primigravida with an enormous leiomyoma. Potential pregnancy complications and pain treatment during pregnancy are discussed in the following work.

Embolization of renal angiomyolipoma in pregnancy: case report.

BACKGROUND: Renal angiomyolipoma is a rare benign tumour composed of adipose tissue, blood vessels and smooth muscles. However it can locally grow to a great size and its numerous blood vessels may cause major bleeding requiring immediate intervention. CASE: At 20th week of pregnancy a previously healthy 26-year old pregnant woman with an episode of sudden and severe pain in the left flank followed by fainting was diagnosed with a bleeding tumour of the left kidney. The diagnosis was based on ultrasonography and magnetic resonance imaging (MRI). Diagnostic angiography was followed by selective embolization of the tumour blood vessels. At 38th week of pregnancy elective caesarean section was performed and after the puerperium the tumour was resected. CONCLUSION: Embolization of renal angiomyolipoma bleeding vessels during pregnancy can be an effective therapeutic approach protecting against further bleeding and haemorrhagic shock thereby obviating the need to perform urgent surgery and allowing the woman to carry her pregnancy to term safely in outpatient setting.

[Recommendations of an expert group appointed by the Polish Gynaecological Society on Prevention of Mother-to-Child Transmission of HIV]. / Rekomendacje Zespolu Ekspertów Polskiego Towarzystwa Ginekologicznego w zakresie zapobiegania perinatalnej transmisji HIV z dnia 24. 10. 2008 r.

The number of HIV-infected women is increasing worldwide. A similar phenomenon has also been observed in Poland, where women constitute 30% of the HIV-infected population. Every year in Poland there are 70-100 infants born by HIV-infected mothers. Since the beginning of the epidemic, 147 HIV-infected children have been registered. The key issue in the prevention of mother-to-child transmission of HIV (PMTCT) is to identify the infection in pregnant women who report to hospitals for delivery and in breastfeeding mothers. In the majority of EU countries, the percentage of pregnant women diagnosed for HIV is over 60%, with some countries (England, Holland, France) where the percentage amounts to as much as 98%. In Poland the proportion is not greater than 10%. Almost all perinatal HIV infections in Poland occured due to the lack of timely diagnosis of the infection in a pregnant woman and the resultant failure to apply known and effective prevention measures. These recommendations present the actual system of care in that population of women in Poland.

[The statement of Polish Gynecological Society experts on oral use of contraceptive 75 microg desogestrel minipill in different clinical cases--state of art in 2008]. / Stanowisko Zespolu Ekspertów Polskiego Towarzystwa Ginekologicznego dotyczace zastosowania antykoncepcyjnej minitabletki gestagennej zawierajacej 75 microg dezogestrelu w wybranych sytuacjach klinicznych--stan wiedzy na 2008 rok.

Recent epidemiologic studies indicate that use of combined oral contraception is associated with a increase in the incidence of cardiovascular disease (venous thromboembolism, pulmonary embolism, myocardial infarction and stroke). The risk of cardiovascular disease is strongly related to estrogen dose, progestogen type and other factors for example thrombogenic mutations and cigarette smoking among female over age 35. The progestogen only contraception is safe alternative to combined hormonal contraception. Progestogen only pill (POP) has different levels of action (local and/or central) which may vary from one drug to another. As for the cardiovascular disease risk, progestogens are not considered to be risk factors. Desogestrel containing POP is advised in the following cases: bad tolerance of exogenous oestrogens; in order to counteract an endogenous hyperoestrogenosis; medical, metabolic or cardiovascular contraindications to estroprogestogen contraception. Lastly, POP should be used as a prime contraception in some particular situations (breast feeding, endometriosis, adenomyosis, cigarette smoking, contraception for older women). These recommendations present the actual system of care in that population of women in Poland.

[Chest ultrasound in the diagnosis of pulmonary embolism in a pregnant patient - a case report]. / Ultrasonografia klatki piersiowej w diagnosytce zatorowosci plucnej u ciezarnej - opis pryzpadku.

Pregnancy is a risk factor for both pulmonary embolism (PE), and an incorrect diagnostic assessment in cases of suspected PE with potentially dangerous consequences for the mother and foetus. The major concern is ionising radiation utilized by diagnostic tests and its potential negative effect on foetal safety. This paper presents diagnostic difficulties encountered in a 31-year-old patient at 20 weeks of gestation who was admitted to hospital with non-specific chest pain and suspected PE as a complication of right lower limb venous thrombosis. The case study reminds of chest ultrasound as a useful tool in the diagnosis of PE. The official clinical practice guidelines do not recommend the use of chest ultrasound for diagnosing of PE due to lack of a sufficient number of published studies. This case report may encourage further, prospective studies in the hope to define whether and when chest ultrasound might find its place in the diagnostic strategy of PE, especially in pregnant women.