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The evaluation of the effectiveness and safety of hysteroscopic management of residual trophoblastic tissue and to verify the miniinvasivity with the second-look hysteroscopy.Prospective study.Department of Gynecology and Obstetrics, First Faculty od Medicine, Charles University and General Teaching Hospital, Prague.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.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.Hysteroscopic resection is a safe and efficient operative technique, which is suitable for management of larger trophoblastic tissue left after delivery or abortion.

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.Case report.Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague.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.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.

Review of the physiological role of neuroactive and neuroprotective steroids in human pregnancy.A review article.Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and General Hospital, Prague.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.

To evaluate the effectivness of a global method of endometrium ablation--Thermachoice (Gynecare; JohnsonJohnson) baloon therapy in treatment of excessive uterine bleeding. Our 10-year-long-experience is presented.Retrospective study.Department of Gynecology and Obstetrics, First faculty of Medicine, Charles University and General Teaching Hospital, Prague.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.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.

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.Review article, case report.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.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.

The authors demonstrate the case of left adnexal torsion caused by 2 benign teratomas in its ovarian and tubal location.Case report.Department of Obstetrics and Gynecology, 1st Faculty of Medicine and General Teaching Hospital, Charles University, Prague.24-years old woman underwent laparoscopy for several days lasting pain in lower abdomen and ultrasound finding of semicystic mass in the left adnexal region with suspicion of teratoma. The benign teratoma of the left ovary together with a torsion of the left Fallopian tube distended by teratoma was revealed during surgery. Left side salpingectomy and enucleation of the ovarian teratoma has been performed. This surprising finding was confirmed by histopathological examination.The acute gynaecological torsion event may be caused not only by torsion of uterine fibroid or enlarged tumorous ovary but rarely also by a teratoma of the Fallopian tube.

To evaluate the negative effect of uterine myoma enucleation forcompact structure of the uterus.Case report.Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, Pronatal Sanatoruim, PragueIn this study, the authors analyze their experience of the course of pregnancy in a patient who had uterine myoma enucleation with penetration to the uterine cavity and large coagulation. The pregnancy was terminated by caesarean section for the indication of prior uterine surgery and the risk of uterine rupture in 38 week of pregnancy.This case report demonstrates the risk of uterine rupture in pregnancy after laparoscopy myoma enucleation.

The method used to terminate pregnancy on medical grounds during the second trimester must be safe, rapid, psychologically feasible and associated with a minimal risk of long-term sequelae. The objective of the present work was a critical analysis of the author's standard protocol of termination of pregnancy during the second trimester.For induction of abortion during the second trimester the authors used a synthetic prostaglandin analogue (PG) F2 alpha-Dinoprost which was administered in a single dose of 30 mg by the intraamniotic route. At the time of onset of uterine contractions the authors administered peridural anaesthesia. The authors investigated indications, mean period of induction, correlation between the period of induction of abortion and the indications for termination of pregnancy, the week of pregnancy and parity of the mother. They recorded also the type and number of complications.From January 1991 till June 1997 179 pregnancies were terminated by intraamniotic PG administration. After a single intraamniotic PG administration 72% women aborted within 24 hours. In 26% women the intraamniotic administration was repeated twice and in 2% women three times. The mean induction period, i.e. the interval between the administration and abortion of the foetus was 22.6 hours. The interval was significantly longer (28 hours) in foetuses where pregnancy was terminated because of a neural tube defect (p0.01). The authors did not detect a correlation between the period of induction and the indication, week of gestation and parity of the mother.once a general reaction to intraamniotic administration, in three patients a major blood loss replaced by transfusion of erythrocyte mass, no uterine rupture.In all instances the therapeutic effect was achieved and there was no need to perform section minor. The disadvantage of the method is the high price of the preparation and need of repeated intraamniotic administration of PG in 29% of the patients.In this study F2 alpha-Dinoprost, a synthetic prostaglandin analogue, was tested for use in inducing abortion in second-trimester pregnancy. During the period of January 1991 to June 1997 a total of 179 pregnancies were terminated by intra-amniotic administration of the drug. The indications for the fetus were congenital abnormalities (59 cases or 32%), intrauterine death (41 cases or 24%), and chromosomal aberrations (20 cases or 11%). For the mother the indications were internal disease, psychological reasons (38 cases or 21%), and unsuccessful abortion in the first trimester. The following procedure was carried out: puncture of the amniotic sac under ultrasound control, intra- amniotic administration of a 5 mg of Dinoprost test dose followed by the whole single dose of 30 mg, continuous infusion of 5 mg of Dinoprost at a speed of 10 gtt/min, peridural analgesia, and instrumental curettage. Peridural anesthesia was administered at the time of onset of uterine contractions. Following a single dose 72 women aborted within 24 hours. The intra-amniotic administration of the drug was performed twice in 48 (26%) women and three times in 3 (2%) women. The mean induction period (the interval between dose administration and the expulsion of the fetus) was 22.6 hours. The interval was significantly longer (28 hours) in fetuses for which pregnancy was terminated because of a neural tube defect (p 0.01). Complications included 1 episode of general reaction to intra-amniotic administration; in 3 patients massive blood loss was replaced by the transfusion of 2 x 300 ml erythrocyte mass. Postabortum residue was encountered in 2 cases, cervical rupture in one case, and phlebothrombosis in 1 case. The disadvantage of the method is the high price of the preparation and, to judge by these results, that it requires repeated administration for a substantial minority (29% or 51) of patients.