[Hysteroscopic diagnosis and treatment of endometrial polyps]

The aim of the retrospective study was to analyse the frequency of polyps, anamnestic data and the result of histological examination overviewing 163 polyps which was find during 1900 hysteroscopy. In the history of patients dilatation and curettage was find in 22% one time and in 6.6% two times, but the polyps were removed by hysteroscopy in the end. The indication of hysteroscopy was haemorrhage in 55%, abnormal ultrasonographic results in 25% and sterility in 15%. During 153 polypectomy were two perforations (0.89%), no other major complication. The result of histological examination of 153 removed polyps was surprising, because in 22 cases proliferative endometrium, in 17 cases hyperplasia, in 6 cases secretory endometrium, in 5-5 cases fibroid and dyshormonal effect and in 1-1 case endometritis, adenomyosis, atrophy and malignant transformation was the histological diagnosis. Despite of relatively high false positive hysteroscopic results, the endoscopic procedure is useful method for treatment of endometrial polyps if the aim is the minimal invasivity and organ saving surgery.

[The healing process following gynecologic laparoscopy: data on the significance of psychological factors]

It is known that patients undergoing laparoscopic surgery can be discharged from hospital sooner and their reconvalescence is achieved faster than after laparotomy. Beside the medical judgement of the healing process it is also important to assess the length of time needed for the patients to feel themselves completely cured and be free of complaints. The data on the subjective judgement of the healing process provided by 335 patients who underwent laparoscopic surgery are analyzed retrospectively here. The aim of the study was to assess how anxiety as a personality trait might influence the healing process and also if there is any connection between anxiety, clinical diagnosis and laparoscopic findings. Anxiety was measured by Spielberger's State-Trait Anxiety Inventory (STAI). The estimated average healing time is 29.8 days (appr. 4 weeks), but patients with diagnostic and/or operative laparoscopy felt themselves free of complaints after 18.9 days (appr. 3 weeks) on the average. The duration of the healing process is independent of the laparoscopic findings and the type of procedure. There is a strong correlation between the anxiety level and the healing process. The average level of anxiety trait was 47.99 +/- 9.50. Anxiety level was the highest in the group of patients operated on for pelvic pain (mean = 51.21). There was no serious organic alteration in the small pelvis in 37% of the cases. One year after the operation 11.3% of the patients did not feel themselves cured and 17.6% had complaints. These data emphasize the role of anxiety and that of psychological factors in the etiopathogenesis and treatment of gynecologic diseases, especially in chronic pelvic pain and infertility or sterility.

[Follow up examination of the endometrium during tamoxifen therapy]

Tamoxifen is a non-steroidal estrogen antagonist used mainly in the adjuvant therapy of breast cancer. Tamoxifen acts primarily as an antiestrogen, but also carries estrogenic effect, mainly to the endometrium. Although diverse pathological uterine findings has been described in connection with the long term use of this drug, there is no widely accepted protocol for the monitoring of the endometrium in these patients. All patients referred for gynecologic examination at the Department of Obstetrics and Gynecology University Medical School Debrecen, Hungary with previous treatment for breast cancer were involved in a screening programme. The gradual screening programme consists of: transvaginal sonography, color doppler imaging, hysteroscopy, and endometrial curettage or sampling. If any of the first steps proved to be negative, further evaluation could be avoided. Altogether 31 patients were referred for examination and transvaginal sonography alone excluded endometrial abnormality in 9 cases, while the rest of the patients went through further evaluation. The ratio of false positive results using transvaginal sonography alone was high and could be lowered with additional color doppler imaging. Endometrial pathology could be excluded in about 50% of cases without tissue sampling. Positive histology was found in 25% of patients receiving Tamoxifen. The most frequent pathological finding was endometrial polyp. In conclusion endometrial changes found by transvaginal sonography, should be further evaluated. The gradual screening procedures enable us to the proper use of more invasive procedures.

Trend from laparotomy to laparoscopy in the case of treatment of ectopic pregnancy

Ectopic pregnancy is a very hazardous, life threatening complication of the women. Diagnosis and treatment previously were very conservative. When not typical symptoms were found, only waiting or observing was the main task of hospitalisation and only the beginning of typical signs came laparotomy. Nowadays, with the introduction of vaginal ultrasound, color doppler or power imaging techniques and sensitive blood HCG analysis greatly reduced hospitalisation period. The need for the change from laparotomy to laparoscopic treatment in surgical operations became everyday practice. We analyzed the data in our department for the operation procedures of ectopic pregnancies from 1990.

Operative hysteroscopy: minimally invasive surgery to control of menorrhagia

Diagnostic hysteroscopy is a valuable method for evaluation of intrauterine disorders. After diagnosing, the endoscopic treatment of these pathologies is the major question of past decade. Possibility of solving cause of infertility or abnormal uterine bleeding without laparotomy or hysterotomy/hysterectomy is the great advantage of operative hysteroscopic methods. In Department of Obstetrics and Gynaecology of University Medical School of Debrecen more than 1400 hysteroscopic interventions were performed from 1 September 1989 to 31 December 1996. In treatment of intractable uterine bleeding 347 operative hysteroscopy (targeted biopsy, polypectomy, transcervical endometrial ablation, fibroid resection etc.) were performed. The rate of complications was low, only 2% (4 perforations and 2 bleedings). The high success rate and low rate of complications offers a modern, safe, minimally invasive method for treatment of menorrhagia.

Application of minimally invasive surgery in Mayer-Rokitansky-Küster-Hauser syndrome

With the advancement of endoscopic techniques more and more invasive procedures can be replaced by less harmful interventions. Successful laparoscopic treatment of vaginal agenesis in Mayer-Rokitansky-Kuster-Hauser syndrome is described in four patients.

[Peritoneal hemorrhage caused by trophoblast tissue implanted on the peritoneum 6 weeks following induced abortion]

A case of heavy intraperitoneal bleeding from perimetrical implanted trophoblast tissue on the uterus was reported following artificial abortion. The six weeks previously terminated pregnancy was verified by transvaginal ultrasound examination, the unrecognised simultaneous extrauterine pregnancy was excluded. The mechanism of peritoneal implantation of trophoblast tissue is unknown. The authors reported the successful conservative treatment and analyzed possible origin of this rare localisation of trophoblast tissue.

[Use of erythropoietin in pregnancy: review of the literature in connection with 2 cases]

Recently a growing number of case reports has been published about successful pregnancy outcome of dialysed women on recombinant human erythropoietin therapy. During pregnancy the maternal demand for erythropoietin may undergo changes, with consideration of recombinant human erythropoietin therapy in the early stage of renal insufficiency, as is shown by our two reported cases. The use of recombinant human erythropoietin seems to be safe for the foetus: it does not cross the placental barrier, and therefore lacks any direct foetal effect. The treatment of anaemia with recombinant human erythropoietin carries benefits for both the mother and foetus. One of the most important preconditions for successful recombinant human erythropoietin therapy is adequate iron supplementation. Due to the increased risk of pregnancy induced hypertension or preeclampsia, there is a need for slow and gradual correction of anaemia, and an individually tailored target hematocrit. A close follow up of he patient by the obstetrical-nephrological team is essential, with the intensive monitoring of the fetuses. In some cases with normal renal function the stimulation of erythropoiesis with recombinant human erythropoietin may also be needed during the pregnancy.

Uterine surgery by operative hysteroscopy

Uterine anomalies are found in 10-15% of women with repeated pregnancy loss. Uterine malformations and benign tumors are common causes of abortions, premature labour and abnormal fetal presentation in some cases. One-third of patients with habitual abortion have a septated or subseptated uterus, and two-thirds of pregnancies in women with duplicated uterus progress to term. Müllerian fusion defects and submucous fibroid may cause poor implantation or ineffective maternal blood supply to the placental site of the developing pregnancy. When these abnormalities were evaluated in infertile patients or in habitual abortions, traditionally the abdominal correction (Jones, Strassman, Tompkins etc.) were used traditionally. These procedures require incision of abdominal and uterine walls in general anesthesia with relative long hospitalization and recovery. The new endoscopic procedure; hysteroscopy is used not only to evaluate the type and size of Müllerian fusion defects but also to treat this malformation. The uterine septum is transsectable, via this elegant method, without injury of abdominal wall and healthy uterine wall musculature. After a traditional abdominal metroplasty there is no other-choice other than the cesarean section to prevent rupture of the uterus, but after hysteroscopic septotomy the vaginal delivery is possible and the uterine rupture rarity.

[Bilateral primary lymphoma of the breasts detected in pregnancy]

The authors report a case of bilateral primary malignant lymphoma of the breast presenting during pregnancy in a 24-year-old woman. After delivery of a healthy premature infant by Caesarean section, polychemotherapy was employed. The efficacy of the treatment could not be evaluated since the patient died within a very short period of time. Autopsy and histological examination revealed infiltration of Burkitt-type lymphoma in the breast, ovary, brain, liver, kidney, adrenal gland, pancreas, stomach, bone marrow and myocardium.

Bilateral primary malignant lymphoma of the breast during pregnancy

The authors report a case of bilateral primary malignant lymphoma of the breast presenting during pregnancy in a 24-year-old woman. After the delivery of a healthy premature infant by Caesarean section, polychemotherapy was employed. The efficacy of the treatment could not be evaluated since the patient died within a very short period of time. Autopsy and histological examination revealed infiltration of Burkitt-type lymphoma in the breast, ovary, brain, liver, kidney, adrenal gland, pancreas, stomach, bone marrow and myocardium.

Consecutive appearance of coagulation factor XIII subunit A in macrophages, megakaryocytes, and liver cells during early human development

Thirty embryonic and fetal samples were investigated to study the appearance and characteristics of factor XIII subunit A (FXIIIA)-containing cells in the course of human development. Samples were either vacuum-embedded in paraffin for staining FXIIIA by a sensitive biotin-streptavidin system or snap-frozen for double-labeling studies to characterize FXIIIA-containing cells. FXIIIA appeared as early as the fifth gestational week in yolk sac samples in stellate-shaped cells. Nonparenchymal cells in liver samples showed intense labeling for FXIIIA from the sixth week of gestation. The relative amount of FXIIIA-containing cells rapidly diminished up to the 13th gestational week. When characterized, the majority of these cells proved to be KiM7-positive macrophages, while GPIb (CD42b)-labeled cells accounted for less than 10% of FXIIIA-positive cells. Liver cells did not show any staining for FXIIIA in first trimester samples. The earliest liver specimen showing FXIIIA was at the 20th week, when FXIIIA appeared in some liver cells, particularly in those surrounding the central veins. In bone marrow smears, FXIIIA-positive cells started to appear at week 10 in the clavicles and increased in number in subsequent stages of development. Intracellular FXIIIA was distributed between GPIb-, RFD7-, and KiM7-positive cells. The results indicate that, apart from liver cells, at least three different cell populations (KiM7+ RFD7+ GPIb-, KiM7- RFD7- GPIb-, and KiM7- RFD7- GPIb+) contain FXIIIA in the early phase of human development. We conclude that FXIIIA appears very early during human development and is detectable in both extra- and intraembryonic hematopoietic organs. Intracellular FXIIIA in early human development is distributed between different macrophages and megakaryocytes, and by week 20, it appears in liver cells as well.

Hysteroscopic vaginoscopy in the diagnosis of vaginal bleeding

Acomplete gynecological examination of young children and senile patients requires special considerations and techniques. Due to the intact hymenal ring or the very narrow, atrophic vagina, the routinely used instruments, specula, will not allow sufficient visualization. To establish exact diagnosis and apply adequate therapy, proper examination of the vagina is required. For this purpose Huffman-Huber or Cameron-Muller equipment is traditionally used (Fig. 1). A modified Foley catheter was used by Redman, further improving the obtained picture, and the application of a balloon vaginoscope has been described by Terruhn. In spite of all these developments, examinations frequently turn out to be difficult due to insufficient vaginal wall distension and bleeding. Based on our previous experience, we describe a modified vaginoscopy, using hysteroscope and continuous liquid irrigation.

Onset and distribution of factor XIII-containing cells in the mesenchyme of chorionic villi during early phase of human placentation

To learn more about the distribution and possible function of factor XIII (FXIII)-containing cells of human placenta, paraffin embedded and frozen sections of placenta samples from the first trimester of pregnancies--terminated by legal abortions--were studied by single and double labelling immunomorphological techniques. It was observed that at the fifth gestational week in the chorionic mesenchyme, FXIII-containing small mononuclear, round shaped cells start to appear. The relative amount of the FXIII-containing cells rapidly increased up to the seventh gestational week, reaching nearly 30 per cent of all mesenchymal cells. Simultaneously these cells differentiated into large stellate cells having numerous vacuoles in their cytoplasm. These cells were characterized in double labelling experiments and proved to be macrophages (CD 14+, KiM7+, labelled with antimacrophage monoclonal antibody). In the fifth-seventh weeks of gestation, these cells were homogenously scattered in the immature mesenchymal connective tissue, but from the eight gestational week they tended to accumulate in the peripheral part of chorionic villi while the central mesenchyme showed intense fibrotic changes. The abundance and characteristic distribution of the FXIII-positive macrophages in the chorionic mesenchyme during the first trimester of pregnancy suggest that these cells may have an active role in the formation of connective tissue in the early phase of placentation.

[Use of the resectoscope in surgical hysteroscopy]

52 women were treated with hysteroscopic interventions with resectoscope. Using continuous liquid irrigation transcervical resection of endometrium (8) and fibroids (9), septotomy (10), polypectomy (7), "deep" biopsy (8) and adhesiolysis (5) were performed without important complications. Special application of resectoscope for vaginoscopy is a new possibility of pediatric gynecology diagnosing vaginal bleeding and injury (5).

[Determination of the functional state of the uterine tube by hysteroscopy]

The authors present their observations on the uterine os and signs of patency of the Fallopian tubes based on 240 cases of infertility examined by hysteroscopy. The shape of the cornual region, the adjacent pathological structures, ie., adhesions, polyps, fibroids etc., the outflow of the distending medium towards the Fallopian tubes and the movement of the tubal os were visualised. Intrauterine pressure and flow data were recorded in order to judge tubal patency. The funnel-shaped (in contrast with the flat type) cornual region, rhythmic contraction of the tubal os, the outflow of distending medium, intrauterine pressure under 100-120 Hgmm and standard 25-50 ml/min medium flow were evaluated as characteristic diagnostic signs of tubal patency.

[Concomitant laparoscopy and hysteroscopy in the evaluation of female infertility]

Fifty sterile women underwent concomitant laparoscopy and hysteroscopy for evaluation of infertility. Authors compare results of hysterosalpingography to result of this double endoscopic method. Authors analyse the different results of hysteroscopy with laparoscopy and hysterosalpingography.

[Pregnancy in mixed connective tissue disease]

The authors carried out a retrospective study of the pregnancy of 31 women suffering from mixed connective tissue disease (MCTD). They summed up the number of growing children, stillborns, and spontaneous abortion in the period before and after commencement of the disease process. Their results point to a rather marked occurrence of spontaneous abortion even in the period before the actual disease process. In the majority of patients there were observable clinical signs which, retrospectively, was an autoimmune disease process, but now known as the appearance of MCTD. In the period following the disease only a smaller percentage of patients became pregnant, not on account of their age or previous spontaneous abortions, but rather because of their symptoms. They investigated those clinical abnormalities which could be reasons for the adverse conditions for fetal development in MCTD.