Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta.

Objective: We aimed to assess the predictive values of individual sonographic findings of abnormal placentation to determine the candidates for segmental resectionStudy design: This was a retrospective review of 43 pregnancies with at least one prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta with suspected abnormal placentation in the third trimester at our institution from 2015 through 2017. Sonographic images were reviewed by an investigator blinded to pregnancy outcome. Sonographic parameters were assessed including loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Parameters were analyzed to predict candidates for conservative approach.Results: There were 27 cases with cesarean hysterectomy where as conservative approach was successful in 16 of the cases. Numbers of transfusions of packed red blood cells (2.6 vs. 1.7), fresh frozen plasma (2.3 vs. 0.9) and mean smallest retroplacental myometrial thickness (1.3 vs. 2.1 mm) were significantly different between the two groups (p < .05). Smallest retroplacental myometrial thickness was a significant predictor for the cases appropriate for successful conservative approach (Area Under Curve, AUC =0.911, p < .001), optimal cut off value was obtained at 1.6 mm with 94% sensitivity and 85% specificity.Conclusions: Our data showed that among some sonographic findings of abnormal placentation, smallest myometrial thickness was a significant predictor to determine candidates for conservative approach.

Early low molecular weight heparin for postpartum hemorrhage in women with pre-eclampsia. Is it effective to prevent consumptive coagulopathy?

Background: Postpartum hemorrhage has been one of the most common cause of maternal morbidity and mortality. An association between pre-eclampsia (PE) and postpartum hemorrhage has been shown in previous studies. The aim of this study was to compare some characteristics of postpartum hemorrhage between women with and without PE.Methods: Some characteristics of postpartum hemorrhage were compared between women with (n = 34) and without PE (n = 34). Majority of the cases underwent low molecular heparin administration at postpartum eighth hour, however, in cases who did not give satisfactory responses to blood product transfusions, to block suspected disseminated intravascular coagulation (DIC) secondary to the PE induced vascular injury, low molecular weight heparins were started within 2 h of postpartum hemorrhage. Some characteristics of cases with and without PE and with and without early low molecular weight heparin administration were compared.Results: There were five cases who needed massive transfusions in group with PE, conversely, no case required massive transfusion in group without PE (p < .05), in these five cases prophylactic dose low molecular weight heparin was started within 2 h of postpartum period, these cases determined according to the changes in hematocrit, platelet, and fibrinogen levels with corresponding transfusions. Mean systolic and diastolic blood pressures were significantly higher in PE group. Highest lactate dehydrogenase (LDH) level during follow up was significantly higher in group with PE. Mean numbers of erythrocyte, thrombocyte, and fibrinogen transfusions were significantly higher in PE group. Duration of hospital stay was also significantly higher in group with PE.Conclusions: Postpartum hemorrhage in women with PE may be resistant to blood product transfusions due to DIC and vicious cycle can be blocked by early low molecular weight heparin administration.

Continuous oxytocin versus intermittent oxytocin for induction of labor: a randomized study.

Objective: To assess whether intermittent usage of oxytocin infusion increases the duration of the active phase of labor and reduces maternal and neonatal complications or not.Materials and Methods: A prospective randomized controlled study was conducted of 200 consenting women with singleton pregnancy in the vertex position undergoing labor induction or augmentation at the Zeynep Kamil Maternity and Children's Training and Research Hospital. Participants with cervical dilation of 3 cm were randomized to either continued or intermittent oxytocin infusion when cervical dilation reached 5 cm. The primary outcome measures were the duration of the active phase of labor, defined as the period of labor from 5 cm of cervical dilation to vaginal delivery. Secondary outcomes were the duration of oxytocin infusion, mode of delivery, hyperstimulation, abnormalities in fetal heart rate, perineal tears, and neonatal outcomes.Results: The median duration of the active phase for the women with a vaginal delivery was longer in the intermittent oxytocin group than the continued oxytocin group, but it was not statistically significant (median, 6.91 vs. 7.58 h, p = .37). There was a significant difference in the duration of oxytocin infusion (median, 12.38 h in the intermittent group vs. 15.79 h in the continued group, p = .005). The incidence of uterine hyperstimulation was significantly greater in the continued group (21.1%) than the intermittent oxytocin group (3.8%) (p=.001).Conclusions: Intermittent usage of oxytocin infusion seems to make labor less complicated without lengthening duration of labor.

Does minimally invasive surgery reduce anxiety?

Objective: To evaluate whether there were any differences in preoperative and postoperative anxiety in patients who underwent total laparoscopic hysterectomy (TLH) (n=37) and total abdominal hysterectomy (TAH) (n=37). Material and Methods: All premenopausal patients who underwent TLH or TAH because of benign uterine disorders were enrolled. Anxiety status was assessed 6 hours before and after the operation using standardized validated questionnaires: State-Trait Anxiety Inventory. Results: In the TAH group, the state anxiety level of the patients significantly increased, whereas there was a significant decrease in the TLH group. For the trait anxiety level, there was a statistically significant increase in the TAH group postoperatively. In the TLH group, trait anxiety levels decreased postoperatively. In the analysis of between-group differences, pre and postoperative the state anxiety level was higher in the TAH group. A statistically significant difference was determined between the groups in respect of the postoperative state anxiety levels (p<0.05), but not in the preoperative state anxiety levels (p>0.05). Statistically significant differences were determined between the groups in respect of education, occupation, and curettage rates (p<0.05). Conclusion: Women undergoing TLH for benign uterine disease may have lower levels of preoperative and postoperative anxiety than women undergoing TAH.

Maternal serum sestrin 2 levels in preeclampsia and their relationship with the severity of the disease.

OBJECTIVE: To investigate sestrin 2 (SESN2) levels in preeclampsia (PE) cases and uncomplicated pregnancies. METHODS: Cross-sectional study including 26 pregnant women with PE, 24 with severe-PE, and 30 randomly selected healthy pregnant women. RESULTS: The mean arterial pressure, severe proteinuria, number of HELLP syndrome cases, and serum SESN2 levels in the severe PE group were significantly higher than those in the other groups (p < 0.001, p < 0.001, p = 0.006, and p = 0.004, respectively). Negative correlation was found between the birth interval (r = -.262, p = 0.019) and the SESN2 level. CONCLUSION: SESN2 seems to play a role in the pathophysiology of PE, especially in severe PE cases.

Cytological assessment of endometrial washings obtained with Karman cannula using a liquid-based preparation method for the detection of endometrial pathologies.

OBJECTIVE: The aim of this study was to evaluate the diagnostic efficacy and utility of liquid-based cytology in ThinPrep (Cytyc Corporation, Boxborough, MA) for endometrial lesions in patients presenting with abnormal uterine bleeding. MATERIALS AND METHODS: Two hundred and thirteen women scheduled for dilatation and curettage because of abnormal uterine bleeding were enrolled in the study. After providing informed consent, all the women proceeded sequentially to endometrial cytology and then dilatation and curettage. RESULTS: In the premenopausal group, cytological failure was 4.8%, histopathological failure was 2.4%; cytologic insufficiency in the postmenopausal group was 2.1%, and histopathologic insufficiency was 19.6%. When cytologic and histopathological sufficiency rates were compared in all cases, cytologic insufficiency was 4.2% and histopathologic insufficiency was 6.1%. This difference was statistically significant (p < 0.039). The diagnostic accuracy, sensitivity, specificity, PPV, and NPV of the liquid-based endometrial cytology for premenopausal patients were 96.79, 58.33, 97.92, 70, and 96.58%, respectively. In the postmenopausal cases, the accuracy of diagnosis of endometrial cytology was 97.30%, sensitivity 100%, specificity 96.67%, PPV 87.50%, and NPV 100%. When cytologic and histopathologically inadequate cases were excluded, no cytologic and histopathological abnormal findings were found in endometrial thickness cutoff ≤ 5 mm for all patients. CONCLUSION: The use of liquid-based cytology with TVS may contribute to increasing the diagnostic accuracy of the test and reduce unnecessary D&C for women. When TVS is used as a triage indicator, regardless of menopausal status in ≤ 5 mm endometrial thickness cases, endometrial cytology is an absolutely reliable method for detecting cancer.

High estrogen exposure may not be detrimental on endometrial receptivity in women with PCOS.

The study aimed to assess the effect of high estrogen exposure and coasting on cycle outcome in women at risk for developing ovarian hyperstimulation syndrome (OHSS). Retrospective case-control study was conducted to figure out the outcomes of GnRH antagonist cycles in which women were at risk to develop OHSS. Women who underwent coasting (n = 100) were compared with a control group of women who did not undergo coasting (n = 287). Effect of endometrial estrogen exposure was determined by calculating area under curve of temporal estrogen measurements (AUCEM) through the cycle. Among 387 women with PCOS, 100 cases were required to undergo coasting to avoid OHSS. All participants reached to embryo transfer stage and clinical pregnancy rate was 44% in group with coasting whereas 39% in group without coasting (p > .05). AUCEM was a significant predictor for the cases who required coasting to avoid OHSS (AUC = 0.754, p < .001). Optimal cut off value was calculated to be 6762 with 71% sensitivity and 67% specificity. ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women with coasting (AUC = 0.496, p > .05). Consistently, ROC analysis showed no predictive value of AUCEM for clinical pregnancy in subgroup of women without coasting (AUC = 0.494, p > .05). In conclusion, neither coasting nor the high endometrial estrogen exposure was found to have detrimental effect on endometrial receptivity and cycle outcome in PCOS.

Comparison of readmission rates between groups with early versus late discharge after vaginal or cesarean delivery: a retrospective analyzes of 14,460 cases.

AIM: The aim of this retrospective analysis was to show the readmission rate of cases with and without early discharge following vaginal or cesarean delivery. METHODS: After exclusion of cases with pregnancy, delivery and neonatal complications, a total of 14,460 cases who delivered at Zeynep Kamil Women and Children's Health Training and Research Hospital were retrospectively screened from hospital database. Subjects were divided into two groups as Group 1: early discharge (n = 6802) and Group 2: late discharge (n = 7658). Groups were compared in terms of readmission rates and indications for readmission. RESULTS: There were 6802 cases with early discharge whereas the remaining women were discharged after 24 h for vaginal delivery and 48 h following cesarean delivery on regular bases. Among cases with early discharge, 205 (3%) cases readmitted to emergency service with variable indications, while there were 216 (2.8%) readmitted women who were discharged on regular bases. Most common indication for readmission was wound infection in both groups. Neonatal sex distributions were similar between groups (p > .05), where as there was a higher rate of cesarean deliveries in Group 2 (p < .05). Furthermore, cesarean rate was significantly higher in readmitted women with early discharge (p < .05). CONCLUSION: Similar readmission rates were observed in groups with early and late discharges following vaginal or cesarean delivery without any mortality or permanent morbidity and cost analyses revealed 68 Turkish liras lower cost with early discharge.

Predictive value of some hematological parameters for non-invasive and invasive mole pregnancies.

AIM: The aim of this study was to discriminate mole pregnancies and invasive forms among cases with first trimester vaginal bleeding by the utilization of some complete blood count parameters conjunct to sonographic findings and beta human chorionic gonadotropin concentration. MATERIALS AND METHODS: Consecutive 257 cases with histopathologically confirmed mole pregnancies and 199 women without mole pregnancy presented with first trimester vaginal bleeding who admitted to Zeynep Kamil Women and Children's Health Training Hospital between January 2012 and January 2016 were included in this cross-sectional study. The serum beta HCG level at presentation, and beta hCG levels at 1st, 2nd and 3rd weeks of postevacuation with some parameters of complete blood count were utilized to discriminate cases with molar pregnancy and cases with invasive mole among first trimester pregnants presented with vaginal bleeding and abnormal sonographic findings. RESULTS: Levels of beta hCG at baseline (AUC = 0.700, p < 0.05) and 1st (AUC = 0.704, p < 0.05), 2nd (AUC = 0.870, p < 0.001) and 3rd (AUC = 0.916, p < 0.001) weeks of postevacuation period were significant predictors for the cases with persistent disease. While area under curve for mean platelet volume is 0.715, it means that mean platelet volume has 21.5% additional diagnostic value for predicting persistency in molar patients. For 8.55 cut-off point for mean platelet volume, sensitivity is 84.6% and specificity is 51.6%. Area under curve for platelet/lymphocyte ratio is 0.683 means that platelet/lymphocyte ratio has additional 18.3% diagnostic value. For 102.25 cut-off point sensitivity is 86.6% and specificity is 46.2. CONCLUSIONS: Simple, widely available complete blood count parameters may be used as an adjunct to other risk factors to diagnose molar pregnancies and predict postevacuation trophoblastic disease.

Vaginal axis on MRI after unilateral and bilateral sacral hysteropexy: a controlled study.

The objective of this study was to evaluate the vaginal position on magnetic resonance imaging (MRI) after bilateral abdominal sacral hysteropexy (BASH) and classical abdominal sacral hysteropexy (ASH) and to investigate which method keeps the vagina the most proximate to its original anatomical position. Ten patients, with 10 having BASH, 10 ASH and 10 being nulliparous, were compared. The angle between the vagina and the pubococcygeal plate, the angle between the upper and lower vaginal segments, the distance between the posterior fornix and the 2nd vertebra and the distances between the lateral fornices and spina ischiadica were measured on MRI. A p value less than .05 was considered statistically significant. The distance between the vaginal axis and the left spina ischiadica was greater in the ASH group compared to the control and the BASH group (p = .011, .047), while it was similar between the BASH group and the control individuals (p = .473). The angle between the upper and lower vaginal segments was greater in the ASH group compared to the control group (p = .004), while no significant difference was found between the BASH and control groups (p = .112). BASH keeps the vaginal axis at a more proximate location to its original anatomical position. IMPACT STATEMENT What is already known on this subject: In pelvic reconstructive surgery; the anatomic correction serves the functional results. What the results of this study add: On MRI examination bilateral abdominal sacral hysteropexy (mimicking uterosacral ligament), keeps the vagina closer to the original anatomic position than classical abdominal sacral hysteropexy. Hence functional outcomes could be better, especially in the long term. What the implications are of these findings for clinical practice and/or further research: This study may be of interest for clinicians in terms of different methods for pelvic floor surgery and may be of interest for researchers to investigate the relationship between anatomic position and functional outcomes especially in younger patients.

Planned cesarean hysterectomy versus modified form of segmental resection in patients with placenta percreta.

OBJECTIVES: The aim of this study was to compare some clinical characteristics of two different management alternatives in pregnants with placental invasion anomalies. METHODS: We conducted a single-center retrospective study of all patients who delivered with invasive placentation between January 2016 and May 2017. We included only the patients with placental invasion anomaly and planned cesarean section. RESULTS: Fifty-one pregnants met the inclusion criteria. Cesarean hysterectomy was performed in 29 patients and segmental resection in 22. Major intraoperative and postoperative complications were comparable between the two groups. There were significant differences between the groups with regard to gravidity, pre- and post-operative hemoglobin concentrations, number of packed red blood cell transfused, and operation time (p < .05). CONCLUSIONS: An initial fertility conserving surgical procedure is an option in patients with extensive invasive placentation with lesser transfusion requirement and shorter operative time compared to cesarean hysterectomy.

Area under the curve of temporal estrogen and progesterone measurements during assisted reproductive technology: Which hormone is the main determinant of cycle outcome?

AIM: Is there any relationship between estrogen and progesterone concentrations during assisted reproductive technology (ART)? Which hormone is the main determinant of impaired endometrial receptivity? METHODS: This study was conducted from July to December 2016 at the in vitro Fertilization/Intracytoplasmic Sperm Injection unit at Zeynep Kamil Women and Children's Health Training and Research Hospital. A total of 289 women who underwent ART were prospectively screened and areas under the curve of temporal estrogen (AUCEM) and progesterone measurements (AUCPM) were calculated for each participant. Women were included if they had regular menstrual cycles, normal serum prolactin levels and had not received hormone treatment within three months. ART was indicated in all patients for unexplained infertility. Patients were divided into two groups: with (n = 90) and without (n = 199) embryo implantation. The relationship between the two AUCs and ART success was assessed in terms of embryo implantation and clinical pregnancy. RESULTS: Implantation was successful in 90 (31.1%) women, and a fetal heart rate was detected in 83 (28.7%) cases. There was a significant correlation between AUCEM and AUCPM (r = 0.525, P < 0.001). Multivariate regression analysis showed significant associations between failure of implantation, lack of clinical pregnancy and AUCEM (beta coefficient = 0.311, P < 0.001; beta coefficient = 0.297, P < 0.001, respectively) after adjusting for AUCPM. CONCLUSION: Our data showed that the degree of endometrial estrogen exposure is the main factor functioning as a detrimental effect of ovarian stimulation on endometrial receptivity.

Utility of complete blood count parameters to detect premature ovarian insufficiency in cases with oligomenorrhea/amenorrhea.

BACKGROUND: There are very few biomarkers available to diagnose cases with premature ovarian failure. Some complete blood count parameters have been introduced to be diagnostic biomarkers for several disorders associated with inflammatory process. Due to the evidence that indicated chronic inflammatory process to be underlying pathophysiology in premature ovarian insufficiency (POI), we aimed to assess the predictive value of complete blood count parameters for POI diagnosis. METHOD: A total of 96 women diagnosed to have premature ovarian failure were compared with 110 otherwise healthy women in terms of some basal hormone levels and complete blood count parameters. RESULTS: Mean age was similar between groups. Neutrophil/lymphocyte and mean platelet volume/lymphocyte ratios were significantly higher in group with POI (P < .001, P < .003, respectively). In group with POI, there were significant correlations between anti-Mullerian hormone and follicle stimulating hormone (r = -.30, P <.05), anti-Mullerian hormone and white blood cell count (r = .23, P < .05). Mean platelet volume/lymphocyte ratio significantly predicted cases with POI (AUC = 0.607, %95 CI: 0.529-0.684; P < .001). CONCLUSIONS: Neutrophil/lymphocyte and mean platelet volume/lymphocyte ratios are elevated in POI. There have been some controversies about the value of neutrophil/lymphocyte in POI diagnosis. We suggest mean platelet volume/lymphocyte ratio as a new biomarker in early POI because it is cheap and easily accessible compared to anti-Mullerian hormone.

Assessment of relationships between novel inflammatory markers and presence and severity of preeclampsia: Epicardial fat thickness, pentraxin-3, and neutrophil-to-lymphocyte ratio.

OBJECTIVE: The aim of this study was to evaluate the relation of three new inflammatory markers with presence and severity of preeclampsia and to compare the predictive values of all markers for presence of this setting. METHODS: In this study, a total of 100 consecutive pregnants with a diagnosis of preeclampsia and 40 healthy pregnants between October 2014 and April 2015 were included. Epicardial fat tissue was calculated by two-dimensional transthoracic echocardiography, and pentraxin-3 and neutrophil-to-lymphocyte ratio were measured by using an enzyme-linked immunosorbent assay method and routine blood count analysis, respectively. RESULTS: Epicardial fat thickness (p < 0.001), pentraxin-3 (p < 0.001), and neutrophil-to-lymphocyte ratio (p < 0.001) were found to be significantly increased in the preeclampsia as compared to the healthy pregnants. Furthermore, epicardial fat thickness (p = 0.002), pentraxin-3 (p < 0.001), and neutrophil-to-lymphocyte ratio (p < 0.001) were significantly elevated in the severe preeclampsia compared to mild preeclampsia. In the multivariate analysis, epicardial fat thickness (p = 0.013), pentraxin-3 (p = 0.04), and neutrophil-to-lymphocyte ratio (p < 0.001) were found as significant independent predictors of presence of preeclampsia after adjusting for other risk factors. CONCLUSION: Epicardial fat thickness, neutrophil-to-lymphocyte ratio, and pentraxin-3 are important markers that provide an additional information beyond that provided by conventional methods in predicting presence and severity of preeclampsia.

Maternal-fetal outcome associated with adolescent pregnancy in a tertiary referral center: a cross-sectional study.

OBJECTIVES: This study was conducted to compare pregnancy outcomes of early-middle adolescent, late adolescent and adult women. MATERIAL AND METHODS: The study focused on early-middle adolescent (n = 145), late adolescent (n = 1655) and adult (n = 1585) women who gave birth during 2014 through 2017, utilizing data obtained from the Zeynep Kamil Women and Children's Health Training and Research Hospital. Pregnancy outcomes were determined according to the rates of preg¬nancy complications, including method of delivery, birth weight, as well as the rate of newborn intensive care admissions. RESULTS: Comparisons between the studied groups for various pregnancy complications showed highest rates of pre¬term deliveries (PD), preterm premature rupture of membranes (PPROM) and neonatal intensive care unit admission in early-middle adolescent group, whereas the highest cesarean section rates were observed in the adult group (p < 0.001). CONCLUSIONS: Analysis of the data revealed that adolescent pregnancy, especially the early-middle adolescent pregnancies, is associated with increased risks of adverse pregnancy outcomes.

Predictive value of complete blood count parameters for placental invasion anomalies.

BACKGROUND: The aim of this study was to assess the relationship between some complete blood count parameters and placental invasion anomalies. METHODS: Totally 146 pregnancies who were suspected for placental invasion anomalies underwent complete blood count screening before cesarean section. In all subjects white blood cell, lymphocyte, neutrophil and platelet counts with red cell distribution width (RDW), mean platelet volume (MPV), hemoglobin and hematocrit levels were analyzed. All complete blood count parameters were analyzed to predict placental invasion anomalies. RESULTS: Among 146 pregnancies histopathologically confirmed placental invasion anomaly was diagnosed in 46 cases. There were significant differences between groups with and without placental invasion anomaly in terms of age, neutrophil, platelet count, MPV, RDW and neutrophil to lymphocyte ratio (p < 0.05). Age (AUC = 0.719, p < 0.001), neutrophil to lymphocyte ratio (AUC = 0.639, p= 0.008) and MPV (AUC = 0.807, p < 0.001) were significant predictors for the cases with placental invasion anomaly. In multivariate analyzes age, MPV, RDW and neutrophil to lymphocyte ratio were significantly associated with the placental invasion anomaly. CONCLUSION: In addition to the sonographic findings, simple blood count parameters may be utilized to confirm cases with suspected for placental invasion anomalies.