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The recommendations present the current knowledge and procedures, which can be modified and changed in some cases, after careful analysis of a given clinical situation, which in the future may become the basis for their modification and updating.

Polish Society of Gynecologists and Obstetricians recommendations on supplementation during pregnancy.

The group of experts representing the Polish Gynecologic Society has issued this statement based on the review of available literature on the potential benefits of the use of Macmiror Complex 500 in obstetrical and gynecologic practice. Mixed Vaginitis (MV) eg. the vaginal infection caused by at least two out of the triad of pathogens (fungi, bacteria and Trichomonas Vaginalis [TV]), constitutes the type of vaginitis which is underestimated as for its prevalence. Mixed pathogens are responsible for as much as one third of all vaginal infections. Macmiror Complex 500 contains two active ingredients: nifuratel and nystatin. Macmiror Complex 500 affects all common causes of vulvovaginitis, i.e. bacteria, yeasts and TV. At the same time, it is not effective against Lactobacillus spp., which is a clear advantage in the treatment of vaginal infections. The antibacterial spectrum of nifuratel includes aerobic and anaerobic bacteria. Moreover nifuratel is effective against Chlamydia trachomatis and Mycoplasma spp., it has an anti-trichomonal effect comparable to metranidazole and shows certain activity against Candida spp. Nystatin is effective against Candida albicans and is even very effective against Candida glabrata which is usually more resistant to imidazole antifungal agents. Nystatin's importance is rising due to the current increase of candidoses caused by non-albicans types. This increase is especially perceptible in recurring candidoses. The review of the available literature on the effectiveness of Macmiror Complex 500 in the OB/GYN practice leads to the following conclusions: the exeptionally broad antibacterial and antifungal and trichomonicidal activity of this formulation makes it a drug of choice in cases where MV is suspected. The possibility to treat both partners, favorable safety profile in pregnant patients and the availability of both vaginal ovules and the cream with applicator makes this drug an effective and suitable treatment option in obstetrical and gynecologic practice.

Endometriosis is defined by endometrial glands and stroma outside of the endometrial cavity Three types of endometriosis have been described: peritoneal endometriosis, ovarian endometriosis and deep infiltrating endometriosis. Endometriosis afflicts 6-15% of women population. It occurs mainly in the group of women in reproductive age, but also in the group of minors and approximately 3% of women after menopause. Within the group of women suffering from infertility the frequency of endometriosis increased to 35-50% of cases. Endometriosis is associated with pain symptoms which can bear the character of pain occurring periodically and altering into constant pain, dysmenorrhea, dyspareunia, dysuria and dyschezia. The correlation between the stage of endometriosis and intensity of pain symptoms not always has to be proportionate. Laparoscopy can be perceived as a standard procedure in endometriosis diagnostics as it allows simultaneous treatment. Profound interview as well as visual diagnostics (USG, MRI) should precede laparoscopy Treatment of endometriosis can be divided into pharmacological and surgical treatment, which can be invasive or non-invasive. The type of treatment depends on patient's age and her procreation plans, occurring ailments and endometriosis type. Important role is played by adjuvant treatment such as appropriate diet and lifestyle. Treatment of advanced endometriosis should be conducted in reference centres that are appointed with adequate equipment and have the possibility of interdisciplinary treatment. Presented standards can digest and outline the order of proceedings both in diagnostics and endometriosis treatment. The research group believes that the above compilation will facilitate undertaking appropriate decision in diagnosis and treatment of the disease, which will subsequently contribute to therapeutic success.

Maternal obesity (defined as prepregnancy maternal BMI> or = 30 kg/m2) is a risk factor strongly associated with serious perinatal complications and its prevalence has increased rapidly in a general population during the last decades. Therefore, following international approach to regulate perinatal care in this population, Group of Experts of Polish Gynecological Society developed these new guidelines concerning perinatal care in obese pregnant women, including women after bariatric surgery. The recommendations cover detailed information on specific needs and risks associated with obesity in women of reproductive age, pregnancy planning, antenatal care, screening, prophylaxis and treatment for other pregnancy complications characteristic for maternal obesity fetal surveillance, intrapartum care and post-partum follow-up. Pregnancy planning in these patients should involve dietary recommendations aiming at well balanced diet and daily caloric uptake below 2000 kcal and modest but regular physical activity with sessions every two days starting from 15 min and increased gradually to 40 min. Laboratory work-up should include tests recommended in general population plus fasting glycemia and oral glucose tolerance if necessary thyroid function, lipidprofile, blood pressure and ECG. Patients after bariatric surgery should allow at least one year before they conceive and have their diet fortified with iron, folic acid, calcium and vit. B12. Antenatal care should include monitoring body weight gain with a target increase in body weight less than 7 kg, thromboprophylaxis, strict monitoring of blood pressure and diagnostic for gestational diabetes in early pregnancy. Fetal ultrasonic scans should be arranged following protocols recommended by US section of Polish Gynaecological Society with additional scan assessing fetal growth performed within 7 days before delivery and aiming at assessing a risk for shoulder dystocia in a patient. Intrapartum care should be delivered in referral centers where fetal and maternal intrapartum complications can be addressed, preferably equipped with a proper medical equipment necessary to deal safely with extremely heavy individuals. Medical staff taking intrapartum care for obese parturient should be also aware of reduced reliability of methods used for intrapartum fetal surveillance, increased risk for intrapartum fetal death, maternal injuries, postpartum haemorrhage, shoulder dystocia, thrombophlebitis and infection. Pediatrician should be also available due to increased neonatal morbidity mainly due to meconium aspiration syndrome, hypoglycemia, and respiratory distress syndrome. In puerperium, medical staff should be prepared to deal with breastfeeding disturbances and increased maternal mortality.

Intrahepatic Cholestasis of Pregnancy (ICP) constitutes the most common, reversible liver disease closely connected with pregnancy and spontaneously resolving in puerperium. ICP usually reoccurs in consecutive pregnancies (45-90%), often in a more intensified form. Many compounds (hormones, cytokines, medicines, endotoxins) can impair transport in the hepatocyte, disturb the intracellular transport and increase the permeability of the intercellular connections. As a result, the elements of bile may appear in the peripheral blood. Gestational cholestasis constitutes a classic example of intrahepatic cholestasis. The etiology of ICP is multifactorial with hormonal, genetic and environmental factors participating in the process. The diagnosis is based on the presence of pruritus, elevated values of bile acids in the blood serum and of aminotransferases (aspartic, aminopropionic and gamma-glutamylotranspeptydase (AspAt, AlAt, GGTP)), as well as spontaneous remission in the second or third week after childbirth, of lack of other illnesses causing pruritus and icterus. Clinical and biochemical symptoms of ICP include: pruritus without skin rash (usually after 30 weeks of gestation), mild icterus, steatorrhea etc. Abnormalities in the laboratory tests of the LFT (liver function tests) encompass: an increase in the serum concentration of fatty acids (BA) which can be the first and only laboratory abnormality. Concentrations surpassing 10 micromol/l are considered to be abnormal. Concentration of BA higher than 40 micromol/l allows to recognize a case of severe ICP, connected with the risk of premature delivery presence of the meconium liquor, surgical means of delivery and low APGAR score of the newborn (< 7 pt). In about 80% of pregnant women with ICP, the BA concentration ranges between 10-40 micromol/l, but perinatal results are comparable with uncomplicated pregnancies. Some authors are of the opinion that abnormal AlAt value is the most sensitive test, other authors consider the abnormal values of alkaline phosphatase and bilirubin to be the most pathognomonic factors. Other abnormal tests include: higher activity of alpha-hydroxybutyric dehydrogenase correlated with an increase of the alkaline phosphatase and bilirubin; mild metabolic acidosis; dyslipidemia with elevated concentrations of the total lipids, total cholesterol and free LDL cholesterol and apolipoprotein; abnormal glucose tolerance test. ICP constitutes a medical problem that carries a considerable risk for the fetus, resulting from an increased flow of bile acids to the fetal blood circulation (elevated level in the amniotic fluid, in the umbilical blood serum and meconium). The risk of adverse effects for the fetus correlates with the rise of BA concentration in maternal blood serum. Cholestasis increases the risk of premature labor, presence of meconium in the amniotic fluid, fetal bradycardia, intrauterine asphyxia and stillbirth, particularly when the concentration of serum bile acids on an empty stomach is above 40 micromol/l. However, maternal clinical signs and symptoms do not correlate with the fetal outcome. Aspiration of bile acids or their accumulation in the fetal blood circulation are responsible for the increased frequency of RDS appearing in ICP. The aim of the obstetric management of ICP is to reduce maternal symptoms and biochemical disorders and to minimize the risk of premature delivery fetal distress and sudden death. ICP management should include: bed regime, light, low-fat diet, no stress, upper abdomen ultrasound examination, LFT tests and thrombotic tests once a week, monitoring of the fetal well-being with the available biophysical methods, pharmacotherapy and therapeutic termination of pregnancy in case of serious illness and/or the fetal distress. Ursodeoxycholic acid (UDCA) is the basis of the pharmacological treatment of pregnant women and currently constitutes the most promising treatment option of ICP. UDCA is administered orally in the dosage of 10-16 mg/kg/24, what in practice means 250-300 mg/2-3 times a day.

Nomegestrol acetate (NOMAC) combined with E2 (Zoely) is a monophasic oral contraceptive (OC) which safety and efficacy was confirmed in a number of level I evidence clinical trials. Zoely is highly effective OC, especially in overweight and obese patients, with good cycle control, safe and well tolerated. NOMAC/E2 combination causes no or minimal weight gain and is characterized by minimal influence on bone mineral density or blood pressure and presence of acne. Moreover lipids profile, carbohydrates metabolism, haemostasis and endocrine glands functioning were not affected. High tolerance and acceptance of NOMAC/E2 combination by women, low adverse event profile, fast recovery of ovarian activity and ovulation is a reasonable treatment tool in everyday practice.

An increasing number of immigrants from countries practicing female genital mutilation (FGM) has begun to concern Europe as well. The aim of this article is to present recent medical data about FGM which, in the age of globalisation and migration of people, may become essential for gynaecologists working in Poland, but also those practising abroad.