[Validity of hysteroscopy in clinical setting: single centre analysis of 605 consecutive hysteroscopies]

OBJECTIVE

Hysteroscopy represent standard diagnostic and therapeutic method in the treatment of endometrial pathology, where patient selection for this procedure depends in majority on preoperative uterine ultrasound scan. Hysteroscopy can be used for removal of polyps or myomas, endometrial tumor resection, synechiolysis, sterilisation or removal of remnants from pregnancy. Hysteroscopic surgery can be also an option for patients who wish to preserve the uterus for the treatment of recurrent bleeding. We aimed to evaluate the validity, complication rate and accuracy of hysteroscopy in correlation with preoperative ultrasound and postoperative histopathological findings.

SETTING

Department of Gynecology and Obstetrics, Jessenius Medical Faculty, Commenius University, Martin, Slovak Republic.

SUBJECT AND METHOD

Retrospective analysis of hysteroscopies for period of 24 months.

RESULTS

During study period a total of 605 hysteroscopies were performed. In three (0.5%) cases we did not acquired sufficient bioptic material required for histopathological diagnosis, thus only 602 cases were included in the final analyses. The most frequent indication for hysteroscopy was history of postmenopausal bleeding (35.88%), followed by endometrial polyp (30.9%), hyperplasia (28.24%), cervical polyp (2.32%), corpus alienum in the uterus (1.66%) and fertility disorders (1%). Multifactorial analysis of hysteroscopy, ultrasound and histopathological findings revealed 69.41% sensitivity rate for ultrasound finding of endometrial hyperplasia, 48.16% sensitivity rate for submucous myoma and 81.72% sensitivity for endometrial polyp. The last group of patients showed the highest correlation rate (r)=0.41, p<0.01. The false pozitivity of preoperative ultrasound was 30.59%, 51.84% and 18.28% for mentioned groups, respectively. The association between hysteroscopic and histopathological results showed a 97.1% agreement in patients with endometrial polyp and 89.3% agreement for cases with endometrial hyperplasia (p<0.05). In 66.45% was hysteroscopy associated with biopsy or curretage. The causally surgery (tumor or endometrium ablation, myoma or septum resection) was performed in 27.9% and in 5.65% others types of intrauterine hysteroscopic sugery were done. Out of all surgical procedures polyp ablation represented 63.2%, resection of submucous fibroids 21.2%, endometrial resection or ablation 7.2% and 8.4% others procedures. In studied population we diagnosed 18 (3%) cases of endometrial carcinoma (13 cases associated with hyperplasia, 5 with polyp). Complication rate was 0.66%. Diagnostic hysteroscopic procedures were associated with a significantly lower complication rate (0.19%) than operative procedures (0.82%; p<0.05). The most frequent surgical complication was perforation of the uterine cavity (three cases 0.50%), followed by fluid overload syndrome (0.17%).

CONCLUSION

Hysteroscopy is safe diagnostic and operative method with high sensitivity, particularly for endometrial polyps. The validity of sonography in case of hyperplasia prior surgery could be improved by control uterine ultrasound scan reflecting cycle phase one-two days before surgery.

[Semiquantitative analysis of mRNA aromatase expression in eutopic endometrium as a diagnostic marker of endometriosis and estrogen dependent diseases]

OBJECTIVE

To determine clinical benefits of mRNA aromatase expression in entopic endometrium as a diagnostic marker of endometriosis.

DESIGN

Prospective clinical trial.

SETTING

Department of Obstetrics and Gynaecology of Jessenius Medical Faculty and Faculty Hospital, Martin.

METHODS

The expression of mRNA aromatase of eutopic endometrium was determined among women who underwent laparoscopy or laparotomy due to pelvic pain, infertility or benign pelvic tumor. Endometriosis was confirmed histologicaly and classified by rAFS.

RESULTS

On the basis of entering criteria 23 women were enrolled in this study and divided into two subgroups: 12 endometriotic and 11 without endometriosis. Sensitivity of aromatase expression was 75% and specificity 54.5% at the cut-off value of at least minimal aromatase activity. By the presence of estrogen-dependent diseases- endometriosis, myomas or endometrial hyperplasia 18 women were compared to 5 disease free women. In this case, sensitivity of aromatase expression was 72.2 and specificity 80%.

CONCLUSION

Aromatase expression in eutopic endometrium is a good diagnostic marker for endometriosis.

Association of p53 polymorphisms with breast cancer: a case-control study in Slovak population

Protein p53 is the tumor suppressor involved in cell cycle control and apoptosis. As a transcription factor p53 controls many cell processes and helps in prevention of cancer development. The p53 gene is polymorphic. Polymorphisms can affect the important regions involved in protein tumor suppressor activity. The well-known polymorphisms are the polymorphisms BstUI in exon 4 and MspI in intron 6. Both are supposed to be associated with cancer development. The purpose of this study was to investigate the genotype frequencies and associations of these polymorphisms with breast cancer in Slovak population. We observed the prevalence of BstUIPro (27.47%) and MspIA1 (17.58%) alleles and BstUIPro/Pro (8.79%) and MspIA1/A1 (5.49%) genotypes in breast cancer patients in comparison with controls 23.40%, 14.10%, 5.77%, 1.92% respectively. However the differences were not significant. After division of the cases and controls according to the age the prevalence of the risk alleles and genotypes in women at the age 50 years or less was higher as compared to women older than 50 years. In the younger women group, the p53 BstUI polymorphism genotype frequencies were 6.2% for BstUIPro/Pro, 31.0% for BstUIArg/Pro and 62.8% for BstUIArg/Arg in controls and 11.11 %, 40.74% and 48.15% in cases respectively. The risk of disease for BstUIPro/Pro genotype was more than two-fold higher in comparison with the BstUIArg/Arg (OR=2.34, 95% CI=0.53-10.24). In p53 MspI the genotype frequencies were 1.77% for MspIA1/A1, 24.78% for MspIA1/A2 and 73.45% for MspIA2/A2 in controls and 11.11%, 18.52% and 70.37% in cases respectively. The risk of disease for MspIA1/A1 genotype was more than six-fold higher in comparison with the MspIA2/A2 (OR=6.55, 95% CI=1.02-41.98). When we evaluated the association of both polymorphisms together with the breast cancer risk we observed that the highest risk was connected with the genotype BstUIPro/Pro / MspIA1/A1 (OR=2.99, 95% CI=0.69-13.06). Our results indicate that both BstUI and MspI p53 polymormphisms might play the role in the breast cancer development especially in women younger than 50 years.

Uterine activity and ductus venosus flow velocity patterns during the first stage of labor

OBJECTIVE

To analyze the effects of uterine contractions on ductus venosus (DV) pulsatility during the first stage of labor.

METHODS

Twenty healthy women were examined. Measurements were taken at three stages of cervical dilatation (<4 cm, 4-7 cm and >or=8 cm) during and between contractions. Peak velocity during ventricular systole (S) and atrial contraction (A), pulsatility index for veins (DV PIV), ductus venosus index (DVI) and the S/A ratio were measured.

RESULTS

The DV was observed successfully in 16 cases. The mean S velocity did not change significantly (64 cm/s during and 65 cm/s between contractions). The mean A velocity decreased significantly from 35 cm/s measured between contractions to 29 cm/s during contractions (P<0.0001). The mean DV PIV and DVI were significantly higher during contractions (0.72 and 0.55) than between contractions (0.57 and 0.45) (P<0.0001). There were no significant differences in means between stages of cervical dilatation.

CONCLUSION

Significant differences during and between uterine contractions can be observed in DV pulsatility during normal labor.

[Velocimetry of the ductus venosus in the first stage of labor]

OBJECTIVE

To assess feasibility and physiological variation of fetal ductus venosus Doppler velocimetry during the first stage of labor between uterine contractions.

STUDY DESIGN

A prospective cross-sectional study including 23 healthy women with low-risk pregnancies. Maximum velocities during ventricular systole (S) and atrial contraction (A) were recorded in the ductus venosus between contractions. Pulsatility index for veins (DV PIV) and the ductus venosus index (DVI) were also calculated.

SETTING

Department of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University, Martin.

RESULTS

Acceptable ductus venosus waveforms were acquired in 19 fetuses (83%). The mean +/- SD values of the ductus venosus index and the pulsatility index were 0.46 +/- 0.07 (95% CI: 0.42-0.49) and 0.57 +/- 0.12 (95% CI: 0.51-0.63), respectively. The mean +/- SD values of maximum velocities during ventricular systole (S) and atrial contraction (A) were 65 +/- 8 cm/s and 35 +/- 5 cm/s, respectively.

CONCLUSION

Ductus venosus blood flow velocities can be assessed during labor. This calls for an extension of the detection possibilities of intrauterine fetal status and gives an idea to establish reference ranges for these circulation parameters during labor in the future.

[Is diagnostic curettage sufficient prior to endometrial ablation? Case of an early stage endometrial cancer]

OBJECTIVE

To demonstrate a case of unrecognized endometrial cancer at endometrial ablation.

SUBJECT

Case report.

SETTING

Department of Obstetrics and Gynaecology and Department of Pathology, Jessenius Faculty Hospital, Martin, Slovakia.

SUBJECT AND METHOD

Authors describe a case of an early endometrial cancer diagnosed from material obtained by bipolar loop electrode during endometrial ablation.

CONCLUSION

Authors poing out insufficiency of curettage as a method of endometrial biopsy prior to ablation. Using of the loop electrode may minimize the incidence of unrecognized malignancies.

[TNF-alpha serum levels in women with endometriosis: prospective clinical study]

OBJECTIVE

To determine serum levels of TNF-alpha (tumor necrosis factor alpha) as a prediction of endometriosis.

DESIGN

Prospective clinical case control study.

SETTING

Department of Obstetrics and Gynaecology and Department of Pathology, Jessenius Faculty Hospital, Kollarova 2, Martin, Slovakia.

METHODS

The serum TNF-alpha was determined in women who underwent laparoscopy or laparotomy due to pelvic pain, infertility, dysmenorea or pelvic tumor. Endometriosis was confirmed histologically and classified by rAFS.

RESULTS

On the basis of entering criteria 65 women were enrolled in this study. In 61 cases serum level of TNF-alpha was evaluated. The average serum level of TNF-alpha in the endometriotic group was 73.847 pg/ml (n=30) and without endometriosis was 21.089 pg/ml (n=31). We have found a significant statistical difference between the above mentioned groups in the medium levels of TNF-alpha (p<0.0001). We did not find statistical significance between TNF-alpha levels and in the group of women with endometriosis in relation to the stage of the disease (I.-II., III.-IV., adenomyosis). At a cut-off level of TNF-alpha 30 pg/ml there was a 63.33% sensitivity, 77.42% specificity, a positive prediction value 73.07%, and 68.57% of negative predictive value.

CONCLUSION

TNF-alpha serum levels are good diagnostic markers of endometriosis in the spectrum of noninvasive methods.

[Laparoscopy in chronic pelvic pain--a prospective clinical study]

OBJECTIVE

The aim of this study was to analyze the incidence, causes and management in women with chronic pelvic pain and to evaluate the role of laparoscopy.

DESIGN

A prospective non-randomized clinical trial on 86 women with chronic pelvic pain.

SETTING

Clinic of Gynecology and Obstetrics, JMF CU Martin, Slovak Republic.

METHODS

A prospective clinical trial was performed on 86 patients with chronic pelvic pain, who have undergone laparoscopy from March 2003 to March 2004. Only patients with a pain history of at least 6 month were enrolled into this trial. Specific patient's history characteristics, laparoscopic and cytologic findings were reviewed and analyzed (pain interval, organic findings, preoperative ultrasound examination, previous surgical intervention, oral contraceptive usage, patient's medical history, menstrual cycle regularity, age, presence of dysmenorrhea). In all women, laparoscopy was performed under general anesthesia.

RESULTS

During the study we have performed 309 diagnostic laparoscopic examinations, from which 86 (27.8%) were done due to chronic pelvic pain. The mean patient's age was 35.8 years (19-56). The mean parity was 1.6, ranging from 0-5. Pelvic organ pathology was present in 88.4% of the patients. The most frequent finding was endometriosis (31.4%). According to revised criteria of the American Fertility Society the presence of first, second, third and fourth stage of endometriosis was 55.6, 25.9, 11.1 and 7.4%, respectively. The most frequent occurrence of endometriotic lesions were on ligamenta sacrouterina (21.4%) and plica vesicouterina (19.0%). Pelvic adhesions, myomas, pelvic varicosities and chronic inflammatory process were present in 25.6, 15.1, 9.3 and 3.5% of the cases, respectively. No somatic origin of pain was identified at laparoscopy in 11.6% of patients. Preoperative ultrasonic examination with pelvic pathology findings were performed in 36 patients, and laparoscopy correlated with ultrasonographic findings in 31 (86.1%) cases. The average pain duration was 11.5 months (6-28) with the majority among women with history of previous surgical intervention (48.8%) and parturated women. Presence of pain was most common among women after 31 years of age. Predominantly, cytology examination of biological materials (peritoneal fluid, cyst fluid) revealed an increased histiocytic reaction in coincidence with chronic inflammation process in 31.6%.

CONCLUSION

Invasive laparoscopy in chronic pelvic pain pertains to one of the most important examination procedures for its high specificity and sensitivity. Laparoscopy can reveal organic causes of pelvic pathology in 60% of cases with the possibility of following treatment. Our combined effort should stop the progression of such pathology leading to possible morphologic, functional and psychological alteration, especially among young women in fertile age. Today, endometriosis still remains the main cause of chronic pelvic pain in high percentage rate.