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Case of a primigravid woman who suffered from severe PTMS (postpartum thrombotic microangiopathy syndrome) in the 26th week of pregnancy.Case report.Department of Gynecology and Obstetrics, Hospital Nový Ji#269;ín; Department of Gynecology and Obstetrics, University Hospital Ostrava; Department of Hematooncology, University Hospital Ostrava; Department of Anaesthesiology and Resuscitation, University Hospital Ostrava.A thirty-one-year old primigravid woman was admitted to a secondary level institution due to epigastric pain and spontaneous rupture of membranes at 26th week of pregnancy. On admission her blood pressure was 140/90 mm Hg and an intrauterine fetal death was confirmed. The patients condition deteriorated quickly, resulting in a hypertensive crisis (220/120 mm Hg), which did not respond to medication over a two hour period. Emergency caesarean section was performed, but the patients condition progressed to HELLP syndrome class I, DIC and MOF. She was transferred to the intensive care unit (ICU) of the district referral hospital 38 hours postpartum. On admission to ICU, liver rupture was diagnosed which was managed conservatively. Therapeutic plasma exchange (TPEX) was initiated on day 2 postpartum in response to falling platelets and continued for 6 days. Due to acute kidney injury (AKI), the patient required dialysis for 21 days. The patients condition improved gradually and at 28 days after admission to ICU she was transferred back to the referring hospital. The consensus reached by the treating teams was that PTMS was the most likely diagnosis.This case demonstrates that PTMS improves (usually rapidly) after TPEX is initiated. It also emphasises the importance of maintaining a high index of suspicion for PTMS so that life-saving TPEX can be initiated, because it does not respond to classical treat-ment used in the management of HELLP syndrome. Other research suggests patients may also require a terminal complement blockade with the anti-C5 monoclonal antibody (eculizumab). Further research could focus on diagnostic tests to distinguish PTMS from HELLP to identify which patients would most benefit from these treatments.

Information about an interesting real clinical case.Case repor.Clinic of Gynecology and Obstetrics, University hospital in Ostrava.A 64-year-old female patient with no family history of gynecologic tumors was indicated to total laparoscopic radical hysterectomy due to confirmed squamous cervical carcinoma stage IB1. The operation was converted to laparotomy due to unexpected peroperative finding of ovarian malignancy. Peroperatively, left ovary borderline tumor and tiny implants on the surface of uterus and small pelvis walls were confirmed. Radical abdominal hysterectomy, bilateral salpingo-oophrectomy, omentectomy, appendectomy, pelvic lymphadenectomy and peritonectomy were performed.Definitive postoperative histology further revealed an endometroid adenocarcinoma of the uterus, serous left ovary borderline tumor with non-invasive implants and no residual tumor of cervical carcinoma. In our clinic, several tumor duplicities were reported, but this is the first case of a gynecological tumor triplicity. As far we know, this is the first case report refering to a gynecological tumor triplicity in one time. Keywords gynecologic, multiple, malignancy, radical surgery.

To analyze monochorionic twin pregnancies with twin anemia polycythemia sequence (TAPS) and acute peripartal twin to twin syndrome (aTTTS), to compare their prenatal management and perinatal outcome.Retrospective analysis of monochorionic biamniotic twin pregnancies without signs of chronic TTTS within a period 10/2010 to 10/2013. Further selection of cases with haemoglobin difference in neonates greater than 50 g/l was made, type of feto-fetal haemorrhage was determined and their prenatal and postnatal characteristics were described.Based on the criteria described above we selected four cases out of 55 monochorionic pregnancies. One case of prenatally diagnosed spontaneous TAPS which fulfilled all the diagnostic criteria with typical angioarchitecture inclusive, one case of spontaneous TAPS diagnosed postnatally, a case of postlaser TAPS with a spontaneous resolution and one unusual case of feto-fetal haemorrhage which does not fully meet criteria of TAPS or aTTTS. All the pregnancies were delivered by caesarean section. All the anaemic neonates required blood transfusion postpartum and two of the polycythemic neonates needed partial exsanguination.Rare forms of feto-fetal transfusion syndrome form a heterogenous group and it may be difficult to distinguish between TAPS and aTTTS in certain cases. A recommendation for a management of TAPS cases was published in recent literature. However, correct interpretation of dopplerometric measurments belongs to the hands of experienced ultrasonographers in perinatal centers.

Case report of woman with twin pregnancy complicated by HELLP syndrome which progressed to multiple organ dysfunction syndrome with predominant encephalopathy, renal and respiratory insufficiency with the need to perform repeated therapeutic plasma exchange.Case report.Department of gynecology and obstetrics, University Hospital in Ostrava; Departmet of hematooncology, University Hospital in Ostrava; Department of gynecology and obstetrics, Vsetín hospital; Department of hematology and transfusion, Vsetín Hospital.Case of 35-year-old III gravida/II para with previously normal ongoing twin bichorionic biamniotic pregnancy in week 35+0, which was admitted to secondary care delivery room for three days lasting "flu like" symptoms and the right upper quadrant pain. She was icteric, exhausted, but normotensive (120/75 mm Hg). Acute caesarean section was performed for suspected fetal hypoxia and HELLP syndrome. The laboratory exams confirmed coagulopathy and HELLP syndrome second class during the operation. Blood loss was 800 ml. Despite standard treatment of HELLP syndrome, the condition had developed to renal insufficiency, bilateral fluidothorax, alveolar pulmonary edema, encephalopathy and hypertension. In laboratory results dominates markers of coagulopathy, thrombocytopenia and microangiopathic hemolytic anemia with presence of schistocytes. Due to multiple organ dysfunction syndrome with hemolysis of unclear origin, patient was transferred to referral hospital on sixth postoperative day. Therapeutic plasma exchange (TPEX) was promptly begun. Improvement of laboratory parameters occurred already after the first TPEX and after two days there was a significant improvement of neurological status. Nine TPEX procedures were performed. The treatment was terminated after platelet count reached 100×109/l. She was discharged from hospital 21 days after delivery. After exclusion of other clinical entities, the case was closed as postpartum thrombotic microangiopathic syndrome.Postpartum thrombotic microangiopathic syndrome includes states, which resemble HELLP syndrome with their laboratory result and clinical expression, but their behavior is different - progressively worsening with signs of disseminated intravascular coagulation and complex microangiopathy with multiple organ dysfunction. It is not responding to classic treatment of HELLP syndrome. In this cases usually improvement of patients condition follow initiation of therapeutic plasma exchange.

The aim of this review is to analyze the existing possibilities of using ultrasound in the diagnosis of the fetal inflammatory response.Review.Gynekologicko-porodnická klinika, Fakultní nemocnice Ostrava.Preterm delivery is defined as a delivery before completed 37 weeks of gestation. Approximately one-thirdof these cases is associated with preterm premature rupture of membranes. About forty percent of preterm premature rupture of membranes is complicated by the fetal inflammatory response syndrome, which is associated with the development of severe perinatal morbidity. Recent prenatal diagnosis of the fetal inflammatory response syndrome is based on the invasive methods (amniocentesis, cordocentesis), which are limited by several risk factors accompanying these procedures and technical difficulties. Therefore, there is an effort to replace them by non-invasive approach. The development of ultrasound, as a diagnostic method through the last decade, and knowledge of pathophysiological and morphological changes in fetal organs associated with the fetal inflammatory response may lead to more specific diagnosis in the future and improvement of neonatal outcome.Early identification of fetuses affected by FIRS in pregnancies with PPROM is necessary for right management of these pregnancy pathology. At this moment, ultrasonography examination of fetal lineal vein and fetal echocardiography, seems to be suitable for diagnosing FIRS.

To summarize the knowledge about the effect of selective progesterone receptor modulators and their use in the treatment of myomas in women of childbearing age and in perimenopause.Review article.Long-term treatment with ulipristal acetate maximizes its effectiveness, it helps to achieve faster bleeding control and increases the number of pa-tients with fibroid volume reduction of more than 50%. Ulipristal acetate is the most effective drug in the medical treatment of myomas and its use will change the approach to surgical treatment.

To summarize the knowledge of the effect of selective progesterone receptor modulators and their use in the treatment of myomas in women of childbearing age and in perimenopause.Review articleResults: Long-term treatment with ulipristal acetate maximizes its effectiveness, it helps to achieve faster bleeding control and increases the number of patients with fibroid volume reduction of more than 50%. Ulipristal acetate is the most effective drug in the medical treatment of myomas and its use will change the approach to surgical treatment.

This article is meant to be a complement to the new statement "Assisted vaginal delivery" of the Section of perinatal and fetomaternal medicine (SPFM) of the Czech Society of Gynecology and Obstetrics ČLS JEP, which is also published in this issue of Czech gynecology. The new statement has been formed as a synthesis of two previous separate statements of the SPFM "Vacuumextraction" and "Forceps delivery" and has also been updated based on new scientific knowledge. This review publication summarizes latest knowledge on vacuumextraction and forceps delivery and adds comments to certain points from the statement.A review of the literature.

The evaluation of the risk and protective factors for pelvic floor trauma in relation to vaginal delivery.Review.Department of Obstetrics and Gynecology, University Hospital of Ostrava.The aim was to provide a comprehensive survey of studies focused on risk factors for pelvic floor trauma following vaginal delivery; and to constitute the relationship between the risk and protective factors and levator ani injury. To state the prognosis of the pelvic floor injury before a child delivery is difficult and almost impossible, but it has been assumed that an operative vaginal delivery (obstetrical forceps) represents a significant risk factor for avulsion. The change in obstetric practice can prevent the injury and thus to reduce an adverse effect.Pregnancy and the methods of childbirth are important factors with an impact on pelvic floor injury, potentially contributing to the development of pelvic organ prolapse, and stress and anal incontinence. The recognition of the factors, the proper training of medical staff in the management of labour, and subsequently the proper treatment of perineal tears should prevent pelvic floor injury.

To draw a comparison between spontaneous vaginal delivery and vacuum-assisted vaginal delivery in relation to the incidence and the type of levator ani avulsion in primiparas.Retrospective observational study. SETTIMG: Department of Obstetrics and Gynaecology, University Hospital of Ostrava.In the study, the primiparas who were from 6 to 12 months after spontaneous vaginal delivery (group A, n = 52) or after childbirth with vacuum extraction (group B, n = 51) underwent translabial 3D ultrasound. The obstetric data had been obtained from the hospital database. Translabial 3D ultrasound examination were performed by two sonographists. The monitored parameter was the distance between urethra and fibres of musculus levator ani - levator urethra gap [6]. The distance longer than 25 mm was considered an avulsion injury [6, 22]. Other parameters assessed in relation to the avulsion were: women's age, BMI, epidural analgesia, episiotomy performance, the length of the first and the second stages of labour, and fetal weight.Musculus levator ani avulsion was diagnosed in 10 women - unilateral in 8 cases and bilateral in 2 cases. In group A, women after spontaneous birth, we noticed avulsion injury in 7.7% of cases, whereas in group B, women after vacuum extraction, we recorded avulsion injury in 11.8% of cases. Thus the use of vacuum extraction is not statistically significant risk factor for avulsion musculus levator ani. Statistically significant difference in comparison group A and B was recorded in BMI, the length of the second stages of labour and episiotomy performance.We did not prove a statistically significant connection between avulsion injury and delivery with the use of vacuum extraction in comparison to avulsion injury incidence in uncomplicated vaginal delivery group (tab. 1). Vacuum extraction does not appear as a risk factor for avulsion in contrast to forceps delivery.