Approach in the treatment of tubal pregnancies

Prikazujemo metode i rezultate rada u liječenju 163 tubarne trudnoće (TT) od 2/1992. do 3/1995. godine Klinike “Merkur” u Zagrebu. Frekfencija TT na broj poroda iznosi 2,2%. Ukupno 26,4% je operirano laparaskopskim pristupom, metodom koja je godinama u stalnom porastu. 1995. godine je 50% TT operirano laporoskopski. Primijenjene laparoskopske metode su: (parcijalna) salpingektomija, salpingo tomi ja, istiskivanje tube, instilacija 50% otopine glukoze. Laparoskopski operirane bolesnice su prosječne dobi od 31 godinu, amenoreje 48 dana, hematoperitoneuma 19 ml, prosječne vrijednosti beta HCG 1650 mlJ/mL (min 77 max 11430). Ranije liječenih zbog steriliteta je 10%, 28% su nerotkinje, 56% imaju namjerni, 28% spontani pobačaj u anamnezi. 13% su imale prethodno TT u anamnezi, 28% ginekološku, a 12,5% abdominalnu operaciju, IUD 9,4%, PID 18,5%. 56% je hospitalizirano kao hitan slučaj, 8% u stanju “shock-a”. Prosječno trajanje zahvata je 38,3 min, signifikantno kraće od laparotomije, kao i prosječno trajanje hospitalizaije 3,7 dana. Sve laparoskopski konzervativno operirane su bile nerupturirane TT, ampularne ili istmične lokalizacije. Prikazane su i tri uspješne instilacije hipertonične otopine glukoze. Dokazane prednosti laparoskopskog pristupa su u kraćem trajanju zahvata, kraćoj hospitalizaciji, manjoj traumi za bolesnicu. Stopostotnom uspješnošću operacijska laparoskopija se potpuno nametnula u modernom liječenju TT.In the period from February, 1992 to March, 1995 163 tubal pregnancies (TP) were treated at the University Clinic of Gynecology and Obstetrics of the Merkur Clinical Hospital in Zagreb. The methods and the results of treatment are presented in this paper. The total of 26.4% of TP’s were treated by laparoscopy, the method constantly increasing in use over the observed period - in 1995 a half of the patients were treated this way. The following laparoscopic methods were applied: (partial) salpingectomy, salpingotomy, “milking” of the tube and instillation of the 50% glucose solution. On the average, laparoscopically treated patients were 31 years old, amenorrhoic for 48 days, with haematoperitoneum of 19 ml and the ß HCG of 1650 mlE/ml (min. 77, max. 11,430). 10% of the patients had been previously treated for infertility, 28% were nulliparous, 56% had a history of artificial and 28% of spontaneous abortions. There were 13% of the patients with previous TP’s and 18.5% with PID, whereas 28% had a gynecological and 12.5% an abdominal surgery. IUD was used by 9.4 % of them. As many as 56% were admitted to the hospital as an emergency case, 8% in the state of shock. The average hospital stay was 3-7 days, the average operation duration 38.3 minutes, both significantly shorter than in cases treated by laparotomy. All cases treated conservatively by laparoscopy were unruptured TP’s located ampullary or isthmically, with the expressed wish for further reproduction. Three cases treated successfully with hypertonic glucose solution are presented. The proven advantages of laparoscopic treatment, such as shorter operation time, shorter hospital stay and minor trauma or the patient are confirmed in this study again. These, together with 100% efficiency make laparoscopy conditio sine qua non in modern treatment of tubal pregnancy

BOTANICAL THERAPY IN POSTMENOPAUSE AS A PART OF COMPLEMENTARY AND ALTERNATIVE MEDICINE

Istraživanja Svjetske zdravstvene organizacije procjenjuju da 65–80% svjetske populacije koristi tradicionalnu medicinu kao osnovni oblik zdravstvene intervencije. Uporaba herbalnih pripravaka, dominantna forma liječenja u zemljama u razvoju, u značajnom je porastu i u zemljama Zapada. Zajednica praktičara konvencionalne medicine ne pridaje komplementarnoj i alternativnoj medicini (KAM) veliko značenje zbog nedostatnih i ponekad metodološki neprihvatljivih studija.¬ S druge strane, većina medicinara i zdravstvenih profesionalaca nije upoznata s kvalitetnim znanstvenim dokazima koji uistinu postoje. Zato je potrebno insistirati na prospektivnim, dobro dizajniranim istraživanjima koja će prikazati stupanj djelotvornosti i sigurnosti postupaka i terapija karakterističnih za KAM. Prikazan je pregled činjenica baziranih na znanstvenim istraživanjima biljaka ili biljnih ekstrakata koji se koriste u perimenopauzalnoj medicini.The World Health Organization estimates that 65%–80% of the world’s population use traditional medicine as their primary form of health care while about half of general population in developed countries uses complementary and alternative medicine (CAM). Many health professionals consider CAM as not serious according to non-adequate research, any compelling evidence base and methodological problems and biases. On the other hand, many physicians are uninformed¬ about the quality of evidence that does exist. Assessment of safety and efficacy of herbal remedies is important issue in future research. Brief facts on the herbals used in postmenopausal medicine are presented and discussed

Psychopharmaca in Pregnancy

Trudnoća je posebno stanje u životu žene u kojem se unutar fiziološkoga mijenjaju i postaju specifične za trudnoću brojne fiziološke funkcije. Zbog toga se mijenja i farmakokinetika pojedinih lijekova. Osim toga tijekom trudnoće većina lijekova prelazi u metabolizam ploda, često i u različitim koncentracijama od koncentracija u krvotoku majke, pa treba posvetiti posebnu pažnju učincima lijeka na plod. U radu posebnu pozornost posvećujemo mogućemu štetnom djelovanju psihofarmaka na plod. Trudnoća je period u kojemu često počinju neki psihički poremećaji, u kojem se nastavlja niz ranije započetih psihičkih poremećaja, u kojima može doći do recidiva nekog psihičkog poremećaja pa je trudnoća počela u fazi terapije održavanja ili prevencije recidiva, a sve na određeni način indicira primjenu psihofarmaka. Osim toga, i sama opstetricijska praksa često provodi primjenu psihofarmaka, posebno anksiolitika, bilo zbog njihova anksiolitičkog djelovanja, bilo zbog njihova miorelaksantnog djelovanja s ciljem preveniranja trudova. U svezi s navedenim činjenicama često se u liječničkoj praksi javlja dilema koliko je opravdana primjena psihofarmaka u trudnoći i laktaciji, kao i u vrijeme planiranja trudnoće, da li više štetimo primjenjujući psihofarmakoterapiju povećavajući rizik od posljedica eventualnih nuspojava kod djeteta, ili je pogoršanje psihičkog stanja majke veća opasnost i za majku i za dijete. Odabir metode liječenja uvijek treba odrediti s maksimalnim individualnim pristupom i uz preferiranje onih metoda i lijekova koji imaju najniži rizik štetnosti i za dijete i za majku.Pregnancy is a special period in the life of a woman, in which numerous physiological functions are changed and become specific for pregnancy. Due to this fact, the pharmacokynetics of some drugs is being changed. Besides, during pregnancy the majority of drugs enter fetal metabolism, often in different concentrations than in the mother’s bloodflow. Thus special attention should be devoted to possible untoward impact of psychopharmaca on the fetus. Pregnancy is the period in which mental disorders often start, a series of earlier disorders continue, relapse of a certain mental disorder can occur, so pregnancy might start in the phase of maintenance therapy or prevention of relapse. All this in a way indicates the application of psychopharmaca. Furthermore, the obstetric practice itself often applies psychopharmaca, particularly anxiolytics, either because of their anxiolytic activity or because of their myorelaxant action with the aim of preventing contractions. With regard to the mentioned facts, in clinical practise often emerges a dilemma how much is the application of psychopharmaca in pregnancy and lactation justified, as well as in the period of planning a pregnancy. The question is whether we harm more by applying psychopharmaca with increasing the risk of possible side effects in the child or the determination of mother’s mental condition is a greater danger both for the mother herself and for the child. The choice of treatment methods should always be determined with maximal individual approach and with preference of methods and drugs with the lowest risk of harm for the child and the mother

IDIOPATHIC THROMBOCYTOPENIA IN PREGNANCY Case report

Prikazana je 41 godišnja trudnica kojoj je u 25. tjednu trudnoće otkrivena idiopatska autoimuna trombocitope-nija. Radi se o drugoj trudnoći u drugom braku. Trudnica nije imala znakove hemoragijske dijateze. Broj trombocita kod prijema bio je 4×109/L. Liječenje kortikosteroidima nije dalo rezultate, te je započeto liječenje imunoglobulinima na što broj trombocita kratkotrajno poraste na normalne vrijednosti. Nakon ponovljenog liječenja imunoglobulinima, u 34. tjednu, dovršena je trudnoća carskim rezom. Rođeno je živo, nedonošeno žensko dijete 1980 g/43 cm, bez kliničkih i laboratorij-skih znakova trombocitopenije. Babinjača je preseljena na Hematološki odjel. S obzirom na neodgovaranje na uobičajeno liječenje bolesnici je predložena splenektomija na koju ona ne pristaje. Dijete je otpušteno kući kao zdravo bez ikakovih znakova bolesti.A 41 year-old pregnant woman with idiopathic autoimmune thrombocytopenia detected in her 25th week of pregnancy is presented. It was the second pregnancy in a second marriage. At the beginning of treatement the platelet count was 4×109/L and the disorder was asymptomatic. The patient was treated with corticosteroids without success. The treatement with immunoglobulins produced a transient improvement. Cesarean section was carried out in 34th week of pregnancy, following a second course of immunoglobulin. A baby girl was born with no evidence of neonatal thrombocy-topenia. The woman was transferred to hematologic department. Because of non-respondance to the therapy splenectomy was proposed, but the patient did not agree with the procedure. The child was released home as healthy and entirely unaffected

Evaluation of p16INK4a in cervical lesion of premenopausal and postmenopausal women

Pap smears of postmenopausal women are often misdiagnosed because of the difficulty in distinguishing atrophic epithelial cells groups only by morphological criteria. In this study we investigated the diagnostic application of immunocytochemical staining of p16INK4a on conventional Pap smear. A total of 137 cervical specimens were enrolled in this study, of which 77 and 60 cervical smears were taken from premenopausal and postmenopausal women, respectively. Two cervical smears were taken simultaneously in 68 women, one for conventional cytology and the other for immunostaining. Additional 69 cervical smears were taken from the archive, decolorized and then used for immunostaining. In premenopausal women 1 out of 14 (7.1%) with negative cytology, 7 out of 24 (29.2%) with low grade squamous intra-epithelial lesion (LSIL), all 35 (100%) with high grade squamous intraepithelial lesion (HSIL) and all 4 (100%) with squamous cell carcinoma (confirmed by histopathology) had positive staining to p16INK4a. In postmenopausal women p16INK4a positivity was observed in 4 out of 7 (57.1%) cases of LSIL, 12 out of 14 (85.7%) cases of HSIL and all 4 out of 5 (80%) different cases of carcinoma (1 cervical adenosquamous carcinoma and 3 cervical squamous cell carcinoma in situ confirmed by histopathology), but none of 34 smears with normal cytology. Twenty smears with normal cytology chosen for the negative control in this study were from the group of postmenopausal women and were as expected negative for p16INK4a immunostaining. In the group of postmenopausal women, 16 out of 60 (26.7%) cases the cytological diagnosis was established on the basis of pl6lNK4a immunostaining as being HSIL. From our preliminary study on a limited number of samples, we can however conclude that pl6INK4a immunostaining is a very useful tool for cytological diagnosis enabling to distinguish HSIL from normal, reactive or inflammatory changes

Adjuvant therapy after radical surgery of cervical cancer: Zagreb experience

The results of the analysis of the treatment of 72 patients with carcinoma of the uterine cervix are presented. Seventy-two patients with Stage IB1 carcinoma of the cervix underwent a radical hysterectomy and pelvic lymphadenectomy. The low-risk group includes the patients without unfavourable prognostic factors that were treated by surgery alone. The high-risk group included women with pelvic node metastases, clinical tumour size greater than 3.0 cm, depth of stromal invasion greater than 1/3 of the cervical wall, Grade 3 tumours and the presence of lympho-vascular space involvement. High-risk patients received whole pelvic radiotherapy between two and four weeks following surgery. Thirty-four patients (47.2%) were in the low-risk group and thirty-eight patients (52.8%) were in the high-risk group. Locoregional recurrences were diagnosed in three cases (8.8%) in the surgery group and in four patients (10.5 %) assigned to postoperative radiotherapy. The incidence of distant metastases was 2.9% in the group treated by surgery alone and 5.3% in the group treated by surgery and radiotherapy. Overall survival at five years was 91.2% in the low-risk group and 89.5% in the high-risk group of patients. Five-year overall survival, locoregional and distant metastases were similar in the low-risk and high-risk groups of patients, which emphasizes the value of whole pelvic radiation in patients with one or more unfavourable prognostic factors after radical surgery in Stage IB1 cervical cancer

Adjuvant Therapy after Radical Surgery of Cervical Cancer: Zagreb Experience

The results of the analysis of the treatment of 72 patients with carcinoma of the uterine cervix are presented. Seventy- two patients with Stage IB1 carcinoma of the cervix underwent a radical hysterectomy and pelvic lymphadenectomy. The low-risk group includes the patients without unfavourable prognostic factors that were treated by surgery alone. The high-risk group included women with pelvic node metastases, clinical tumour size greater than 3.0 cm, depth of stromal invasion greater than 1/3 of the cervical wall, Grade 3 tumours and the presence of lympho-vascular space involvement. High-risk patients received whole pelvic radiotherapy between two and four weeks following surgery. Thirtyfour patients (47.2%) were in the low-risk group and thirty-eight patients (52.8%) were in the high-risk group. Locoregional recurrences were diagnosed in three cases (8.8%) in the surgery group and in four patients (10.5 %) assigned to postoperative radiotherapy. The incidence of distant metastases was 2.9% in the group treated by surgery alone and 5.3% in the group treated by surgery and radiotherapy. Overall survival at five years was 91.2% in the low-risk group and 89.5% in the high-risk group of patients. Five-year overall survival, locoregional and distant metastases were similar in the low-risk and high-risk groups of patients, which emphasizes the value of whole pelvic radiation in patients with one or more unfavourable prognostic factors after radical surgery in Stage IB1 cervical cancer

IDIOPATHIC THROMBOCYTOPENIA IN PREGNANCY Case report

Prikazana je 41 godišnja trudnica kojoj je u 25. tjednu trudnoće otkrivena idiopatska autoimuna trombocitope-nija. Radi se o drugoj trudnoći u drugom braku. Trudnica nije imala znakove hemoragijske dijateze. Broj trombocita kod prijema bio je 4×109/L. Liječenje kortikosteroidima nije dalo rezultate, te je započeto liječenje imunoglobulinima na što broj trombocita kratkotrajno poraste na normalne vrijednosti. Nakon ponovljenog liječenja imunoglobulinima, u 34. tjednu, dovršena je trudnoća carskim rezom. Rođeno je živo, nedonošeno žensko dijete 1980 g/43 cm, bez kliničkih i laboratorij-skih znakova trombocitopenije. Babinjača je preseljena na Hematološki odjel. S obzirom na neodgovaranje na uobičajeno liječenje bolesnici je predložena splenektomija na koju ona ne pristaje. Dijete je otpušteno kući kao zdravo bez ikakovih znakova bolesti.A 41 year-old pregnant woman with idiopathic autoimmune thrombocytopenia detected in her 25th week of pregnancy is presented. It was the second pregnancy in a second marriage. At the beginning of treatement the platelet count was 4×109/L and the disorder was asymptomatic. The patient was treated with corticosteroids without success. The treatement with immunoglobulins produced a transient improvement. Cesarean section was carried out in 34th week of pregnancy, following a second course of immunoglobulin. A baby girl was born with no evidence of neonatal thrombocy-topenia. The woman was transferred to hematologic department. Because of non-respondance to the therapy splenectomy was proposed, but the patient did not agree with the procedure. The child was released home as healthy and entirely unaffected