Ascitic Fluid in Ovarian Carcinoma – From Pathophysiology to the Treatment

Due to low symptomatology, a lack of screening, and relatively complicated diagnostic procedures of ovarian carcinoma, more and more women are believed to visit their doctors in advanced stage of the disease, complicated with ascitic fluid. There is an increasing evidence that peritoneal cytology is a subjective assessment with certain percentage of false-positive and false-negative results that may cause application of unnecessary chemotherapy or nonapplication of necessary chemotherapy. Maximal cytoreductive surgery followed by intraperitoneal or systemic chemotherapy remains to be the gold standard in preventing ascites. Ascites is not only a symptom of a disease, but a specific microenvironment for formation and mediation of protumorigenic signals that control ovarian cancer progression, proliferation, invasion, anti-apoptosis, chemoresistance and tumor heterogeneity. Acellular cytokines and immunological factors influence ovarian cancer progression and its ability to prevent immune responses of the body and tumor reaction to chemotherapy. Ascites contributes to disease dissemination, changing its course and final outcomes. Management of patients with ascites and ovarian carcinoma is complex and often the goal of the treatment is to target palliative procedures. Multidisciplinary approach is necessary in the management of these patients. Further investigations of new drugs and immunomodulators are needed aiming at prolonged periods between relapses

Acute abdomen in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome

Background. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a malformation of female genital tract (incidence 1 in 4000 female newborn children). It appears as a result of a disorder in the development of Millerian cannals. Etiology is unknown. Syndrome MRKH is the most frequent cause of primary amenorrhoea (90%). Patients with MRKH have a normal female phenotype, with normal pubic hairness and thelarche, and female karyotype (46XX) followed by primary amenorrhoea. Hormonal status corresponds to healthy women, where the appearance of ovarian tumors and tumors on rudiment parts of uterus is possible. Case report. We presented a case of acute abdomen in a patient with previously not diagnosed MRKH. The diagnosis was done during the operation. Small pelvis and an abdominal part were filled with torquated tumor lump, where ovaries, oviducts, uterus or something resembling rudiment of uterus were not recognized through careful examination. Furthemore, the patient had a short, dead-end vagina. Tumorectomy was done and hystopathological finding showed the presence of vascular leiomyoma. Conclusion. The diagnosis of complex syndromes, such as MRKH, can, despite modern diagnostics, be absent for non-medical and psycho-social reasons. We can expect ovarian and uterine pathology on hypoplastic structures in these patients, as well as in healthy women. Vascular leiomyoma in the patients with MRKH was not found in the available literature

The role of colposcopy and typization of human papillomavirus in further diagnostic proceedings in patients with ASC-US cytological finding of the uterine cervix

Background/Aim. Bethesda system of classification of cytological findings was introduced in 2001 two subcategories in the category of atypical squamous cells (ASC) findings: ASC of undetermined significance (ASC-US) and ASC which cannot exclude high-grade intraepithelial lesions (ASC-H). The aim of our study was to assess a possible association of these two subcategories with pathologic biopsy finding and to find out the best further diagnostic proceedings. Methods. At the Clinic of Gynecology and Obstetrics, Niš 130 patients with ASC findings were analyzed. Colposcopy was performed in all study participants. Patients with pathological colposcopic findings underwent cervical biopsy. In 10 patients with pathologic histologic and 15 with benign findings human papilloma virus (HPV) typization was done using the Hybrid Capture method. Results. Patients with ASC-H finding had significantly more pathologic biopsies compared with patients with ASC-US finding (57.84: 20.72). Conclusion. Colposcopy was exhibited somewhat higher sensitivity compared to HPV typization (94.7 : 90), but lower sensitivity (79.27 : 86.6). The usage of HPV typization in the triage of patients with ASC cytologic smear induces statistically significant reduction of unnecessary percentage of cervical biopsies

Protokół z antagonistą GnRH vs. długi protokół z agonistą GnRH u pacjentek z zespołem policystycznych jajników przygotowywanych do IVF: porównanie wyników klinicznych i jakości zarodków

Objectives: Polycystic ovary syndrome (PCOS) is a common endocrine disorder, primarily affecting women of the reproductive age. The aim of the study was to assess the clinical efficacy and embryo quality in flexible gonadotropin-releasing hormone (GnRH) antagonist protocol in comparison to the long GnRH agonist protocol in PCOS women undergoing in vitro fertilization (IVF). Material and methods: This prospective, randomized study was conducted at the Department of Gynecology and Obstetrics, Clinical Center Niš, Serbia, between 2013 and 2014. The treatment included either a flexible GnRH antagonist protocol (n = 45, antagonist group) or a long GnRH agonist protocol (n = 45, agonist group). Results: The length of the stimulation, total amount of gonadotropins used, as well as the average number of the aspirated and mature oocytes were higher in the agonists group. The endometrial thickness was also greater in the agonists group. A higher number of Class I and Class IV embryos were obtained after the agonist treatment and higher number of Class II and Class III embryos were obtained after the antagonist treatment. Pregnancy, implantation, and miscarriage rates were comparable between the groups. Conclusions: The GnRH antagonist protocol in PCOS patients has a pregnancy rate comparable to that of the GnRH agonist protocol. Since this protocol has a lower rate of complications and is more convenient for patients, we believe that the GnRH antagonist protocol should be used as the first-line treatment for PCOS patients in an IVF program.Cel pracy: Zespół policystycznych jajników (PCOS) jest częstym zaburzeniem endokrynologicznym, głównie dotyczącym kobiet w wieku reprodukcyjnym. Celem badania była ocena skuteczności klinicznej oraz jakości zarodków uzyskanych w protokole flexible z antagonistą GnRH w porównaniu do protokołu długiego z agonistą GnRH u kobiet z zespołem PCO poddanych zapłodnieniu pozaustrojowemu (IVF). Materiał i metoda: To prospektywne, randomizowane badanie przeprowadzono w Klinice Ginekologii i Położnictwa w Clinical Center Niš, w Serbii, w latach 2013–2014. Leczenie polegało na zastosowaniu protokołu flexible z antagonistą GnRH (n = 45) lub długiego protokołu z agonistą GnRH (n = 45). Wyniki: Długość stymulacji, całkowita liczba użytych gonadotropin, jak również średnia liczba zaaspirowanych i dojrzałych oocytów była wyższa w grupie z agonistą. Grubość endometrium była również wyższa w grupie z agonistą. Wyższą ilość zarodków klasy I i IV uzyskano po podaniu agonisty natomiast a po leczeniu antagonistą uzyskano wyższą ilość zarodków klasy II i III. Liczba uzyskanych ciąż, implantacji i poronień była porównywalna w obu grupach. Wnioski: Protokół z antagonistą GnRH u pacjentek z PCOS ma porównywalny odsetek ciąż jak protokół z agonistą GnRH. Ponieważ protokół z antagonistą GnRH ma mniejszą liczbę powikłań i jest wygodniejszy dla pacjentek, uważamy że powinien być stosowany jako leczenie pierwszego rzutu pacjentek z PCOS w programie zapłodnienia pozaustrojowego

The value of Pap test in women with endometrial cancer

Introduction: Endometrial cancer is the second most common gynecological tumor. There is still no recommended screening method for endometrial cancer. The application of transvaginal sonography, hysteroscopy and Pap test may prove useful in screening for this disease. Atypical glandular cells represent an important finding in Pap tests and they are related to histopathological verification of the endometrium. The aim of the study was to determine the usefulness of the Pap test in assessing the cervical infiltration, as well as to determine the significance of hormonal status and histopathological type of tumor in a pathological Pap test in patients with endometrial cancer.Methods: The study was retrospective. The analysis included the data obtained from 62 operated patients diagnosed with enometrial cancer, medical history (menopausal status), histopathological findings after surgery (type and stage of the disease) and a preoperative Pap smear. The chi squared and Fisher’s test were used.Results: The difference in the prevalence of pathological Pap test in premenopausal and postmenopausal group of patients was not statistically significant. The difference in the prevalence of pathological Pap test in the group of endometrioid and non-endometrioid tumours of the uterine corpus had statistical significance. The difference in the prevalence of pathological Pap test compared to the present stage (I and II) was not statistically significant.Conclusion: Pap smear does not correlate with menopausal status in women with endometrial carcinoma. Abnormal Pap test is more commonly found in cases of non-endometroid tumours. Pap smears cannot beused to assess cervical involvement

HYSTEROSCOPY BEFORE IN VITRO FERTILIZATION

In the last decade, success after in vitro fertilization process (IVF) has remained at a similar rate despite all the improvements implemented in the stimulation protocols and laboratory techniques. Hysteroscopy is a method becoming more widely used with patients after a failed IVF cycle, considering a large incidence of uterus cavum pathological states which have a negative impact on the favorable outcome. Numerous studies have provided different results on the IVF outcome with hysteroscopy performed prior to this treatment in cases with no uterus cavum pathology. The aim of the research was to examine the effect of both diagnostic and surgical hysteroscopy on the outcome of IVF.  Hysteroscopy was performed with 74 patients 30 to 50 days prior to IVF and in 33 of them (group I) some pathological state was noticed, which was treated during the same procedure. The control group (group III) included 151 patients who had IVF performed with no prior hysteroscopy. There is no statistically significant difference in the rate of post hysteroscopy implantation between I and II group when compared to the control group (20.62% vs 23.28% vs 17.31%), nor in the rate of clinical pregnancies (45.45% vs 46.34% vs 34.44%). Following the correctional treatment of uterus cavum pathological states, implantation and pregnancy rates remain at a level comparable to hysteroscopically normal medical findings. Statistically significant higher pregnancy rate is present in group I after the first IVF cycle, compared to the next IVF in the same group and in comparison to the next IVF cycle in the control group (60.00% vs 27.91%, p<0.05). Hysteroscopy is a simple and safe method allowing nearly identical rate of clinical pregnancies after a surgical treatment of uterus cavum pathological states when compared to the control group, but statistically much higher pregnancy rate if the order of IVF procedure is being compared. In cases of normal ultrasound findings and negative hysteroscopical findings, performing hysteroscopy prior to IVF does not provide significantly better results. Therefore, its routine execution is not recommended

ASSOCIATION BETWEEN HYPERPROLACTINAEMIA AND OTHER CAUSES OF FEMALE INFERTILITY

Hyperprolactinaemia is one of the major causes of reproductive axis disorders. Adequate treatment for hyperprolactinaemia is very successful in restoring ovulation, but there is still a proportion of patients unable to achieve pregnancy despite adequate control of hyperprolactinaemia. This prospective clinical trial included 104 hyperprolactinaemic patients in reproductive age: 78/104 (75%) suffered from infertility and the other 26 hyperprolactinaemic patients were still unmarried and not interested in pregnancy. Hyperpolactinaemia as the only reason for anovulation and infertility was diagnosed in 43/78 (55.12%) of our patients. In 35/78 (44.88%) patients, hyperprolactinaemia was associated with other causes of infertility: endometriosis, premature ovarian failure, PCO and insulin resistance, etc. After the appropriate treatment, mostly with bromocriptine (in 69/78 – 88.46%, alone or in combination with induction of ovulation), 35/78 (44.87%) patients achieved pregnancy. In the group of infertile patients with hyperolactinaemia as the only cause of infertility, 33/43 (76.74%) patients became pregnant, and in the group of patients who had combination of hyperprolactinaemia and other causes of infertility only 2/35 (5.71%) achieved pregnancy. The treatment of hyperprolactinaemia is obligatory in all patients with infertility. If adequate suppression of serum prolactin levels is achieved, but the pregnancy is still missing despite the fact that ovulatory cycles are established, the other causes of infertility should be searched for, and the clinician should not reject the possible existence of some unknown cause of infertility, so the patient should be referred to ART procedures which give more chances in such circumstances.Key words: Hyperprolactinaemia, infertility, bromocriptine, assisted reproductive technique

VAGINAL CANDIDIASIS – GYNECOLOGICAL ASPECT OF THE PROBLEM

Vaginal candidiasis (VC) is one of the most common reasons for consultations with a gynecologist, with an increasing trend in occurrence in female patients. It is estimated that 75% of all women experience an episode of vulvovaginal candidiasis in their lifetime, 50% of them experience at least a second episode, and 5% have recurrent candidiasis. Cervical and vaginal secretions act as the last line of defense from ascendant infection pathway spreading. Factors that may disturb vaginal ecosystem are: endogenous factors, way of life, infectious factors and iatrogenic factors. The most common cause of VC in 85-90% of cases is C. albicans, but other Candida species tend to be more likely to cause VVC (Candida tropicalis , Candida glabrata , C particulary, C crusei and so on). These non-albicans species have been found to be fluconazole and antimycotics resistant in more than 70% of cases. This is especially true for C. glabrata. There are several predisposing factors that have been associated with VC recurrence and resistance, such as Candida genotypes, resistance and virulence, immunodeficiency, unregulated hyperglycemia, use of oral contraceptives, long-term use of antibiotics. Therapy approach should be individual, including local and oral antimycotics until the symptoms disappear. The maintenance dose can be continuous or intermittent. Due to hormone concentration increase, increase in local glycogen, alternations of vaginal flora, VC incidence in pregnancy is two times higher in comparison to other female population. The problem of vaginal candidiasis requires individual approach, taking into account all the risk factors and accompanying physiological conditions or diseases in female patients

Influence of air pollution on birth weight

Introduction. Epidemiological studies point out that exposure to air pollution during pregnancy is a risk for low birth weight. Objective. The aim of this study was to evaluate the effects of outdoor and indoor air pollution on the occurrence of low birth weight. Methods. The measurement of outdoor air pollutants, sulphur dioxide and black smoke was carried out daily at the Institute for Public Healthcare of Niš at two measuring locations, in Niš and Niška Banja during 2003. Subjects were 367 pregnant women, nonsmokers and who were not profesionally exposed to air pollution. Data on exposure to source of indoor air pollution (passive smoking and mode of heating) was determined on the basis of a questionnaire. Data on the characteristics of newborns were taken from the register of Obstetrics and Gyanecology Clinic of Niš. Results. We determined that exposure of pregnant women to outdoor air pollution and wood heating systems had influence on the occurence of low birth weight. Exposure to passive smoking had no influence on neonatal low birth weight. Conclusion. Exposure of pregnant women to outdoor and indoor air pollutants can have negative influence on the occurrence of low birth weight

Hematological and biochemical markers in determining the diagnosis and stage prediction of endometrial cancer

Objectives: To establish whether there is a statistically significant difference in hematological and biochemical parameters between the patients with premalignant changes of the uterine mucosa and those with malignant changes. The aim is to establish whether hematological and biochemical parameters may be useful in predicting the stages of endometrial malignancy and in differentiating premalignant and malignant endometrial changes. Material and methods: A retrospective study included 100 patients (70 with endometrial carcinoma diagnosis and 30 with atypical hyperplasia). We compared hematological and biochemical parameters in both groups. Results: CRP, granulocytes, platelets, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) are statistically significantly higher in patients with malignant changes. Lymphocyte count is statistically significantly lower in patients with malignant changes. Platelet count is statistically significantly lower in patients with stages I and II in comparison to patients with higher disease stage. NLR and PLR have good discriminatory power for carcinoma presence. Patients with advanced changes have statistically significantly higher CRP values, higher granulocyte and platelet count, as well as higher values of NLR and PLR, and statistically significantly lower values of lymphocytes and MPV in comparison to benign changes. Conclusions: There is a possibility of using hematological and biochemical parameters in the assessment of endometrial changes as well as in the prediction of stages, in confirmed malignant changes of the endometrium