PAPP-A concentrations change in patients with gestational diabetes.

Our aim was to assess the relationship between gestational diabetes and glucose intolerance regarding maternal serum PAPP-A and free ß-hCG concentrations in first trimester pregnancies. This study was conducted on 278 women between 18-45 years old with singleton pregnancies. The subjects were divided into four groups, according to their 50 and 100 g OGTT results. Group 1 was the Control Group, Group 2 with positive 50 g OGTT results, but negative 100 g, Group 3 had gestational diabetes after testing with 50 g OGTT (≥180 mg/dl) or with 100 g OGTT. Finally Group 4 was made of women with a one single high glucose level after testing with 100 g OGTT. These groups were analysed in terms of OGTT results. In the GDM group, serum PAPP-A concentrations were significantly lower when compared with the Control Group's (p = 0.015). There was either no significant differences regarding free ß-hCG concentrations among the groups. GDM rate is 21.1%, the patients with GDM had significantly low concentrations of serum PAPP-A but their f ß-hCG concentrations did not change. Our results are supported by several studies. However, we need greater numbered studies for exact results.IMPACT STATEMENTWhat is already known on this subject? Pregnancy associated plasma protein A (PAPP-A) is produced by the placenta in pregnancy. PAPP-A cleaves insulin-like growth factor (IGF) binding proteins. It would appear to have a role in regulating IGF bioavailability in pregnancy. This is important as the IGF axis plays a critical role in fetal growth, and placental growth and function during pregnancy. Some studies have reported that PAPP-A levels were impaired among women who subsequently developed GDM.What do the results of this study add? The patients with GDM had significantly low concentrations of serum PAPP-A but their free ß-hCG levels did not change.What are the implications of these findings for clinical practice and/or further research? By looking at PAPP-A concentrations, we can predict patients that will be gestational diabetic and take precautions to protect the babies health, such as their diet or exercise.

A Huge Fetal Sacrococcygeal Teratoma with a Vascular Disruption Sequence.

Fetal sacrococcygeal teratomas (SCTs) occur in one to two per 20 000 pregnancies that cause high-output cardiac failure. High-output cardiac failure leads to polyhydramnios, hydrops, intrauterine fetal demise and preterm birth. Vascular disruption defects refer to those involving the interruption or destruction of some part of the fetal vasculature. We present a rare case of huge SCT causing multiple fetal disruption defects like cleft lip and palate and limb anomalies besides hydrops.

Double notches: association of uterine artery notch forms with pregnancy outcome and severity of preeclampsia.

OBJECTIVE: To assess uterine artery Doppler waveforms and notches performed in the third trimester as a predictor of adverse outcomes. METHODS: Of 490 preeclampsia (PE) patients between 24 and 34 weeks gestation, 166 were diagnosed with mild PE and 324 were diagnosed with severe PE. Patients were divided into four groups (no notch, a unilateral notch, bilateral notches and double notches). RESULTS: Bilateral and double notches were predictive of shorter follow-up times, adverse laboratory outcomes, HELLP syndrome, prematurity, neonatal intensive care unit admission and perinatal mortality. CONCLUSION: Double notches represent progressive deterioration in the uterine artery and are predictive of adverse maternal outcomes.

Role of endometrial power Doppler ultrasound using the international endometrial tumor analysis group classification in predicting intrauterine pathology.

PURPOSE: To assess the contribution of the terms and definitions recently described by international endometrial tumor analysis (IETA) group when evaluating endometrial lesions on power Doppler imaging. METHODS: Patients requiring endometrial sampling were examined prospectively by transvaginal B-mode and power Doppler sonography (PDS) the day before scheduled diagnostic procedure. Sonographic features were classified using IETA group classification. These were compared with the final histopathological diagnosis. RESULTS: Ninety-seven patients were included in the study. The histopathological diagnoses were as follows: endometrial polyp: 39 cases (40.2 %), endometrial hyperplasia: 9 cases (9.3 %), submucous myoma: 10 cases (10.3 %), endometrium cancer: 7 cases (7.2 %), non-specific findings: 32 cases (33 %). The sensitivity, specificity and positive and negative predictive values for single dominant or branching single dominant vessel pattern in diagnosing endometrial polyps were 66.67, 98.28, 96.3 and 81.43 %; for multiple vessels with focal origin pattern in diagnosing endometrial cancer, they were 42.86, 91.11, 27.27 and 95.35 %; for multifocal origin at the myometrial-endometrial junction in diagnosing other non-specific endometria, they were 81.25, 89.23, 78.79 and 90.62 %; for scattered vessel pattern in diagnosing endometrial hyperplasia, they were 88.89, 88.64, 44.4 and 98.73 % and for circular flow pattern in diagnosing submucosal fibroids, they were 80, 100, 100 and 97.75 %, respectively. The color score of the endometrium was not statistically different among different endometrial pathologies (P value >0.05). CONCLUSION: The nomenclature described by IETA group for power Doppler assessment of the endometrium is clinically valuable and reasonable. Using this terminology, it will be easier to compare results of different studies on endometrial Doppler sonography in the future.

Management of a Klippel-Trenaunay syndrome in pregnant women with mega-cisterna magna and splenic and vulvar varices at birth: a case report.

Klippel-Trenaunay syndrome (KTS) is a rare, sporadic and complex malformation characterized by the clinical triad of: (i) capillary malformation (port-wine stain); (ii) soft tissue and bone hypertrophy or occasionally, hypertrophy of one lower limb; and (iii) atypical lateral varicosity. The maternal and fetal risks associated with pregnancy in women with KTS are proportional to disease severity, which can be exacerbated by pregnancy. Complications include bleeding, disseminated intravascular coagulation, thromboembolic events and pain. Here, we report the case of a pregnant woman with KTS who had an uneventful pregnancy, labor and postpartum course, but had splenic and large vulvar vein varices. The obstetrical course of women with KTS varies. Management is largely conservative and multidisciplinary approaches form the mainstay for managing these patients based on their symptoms.

Hyberbaric oxygen increases atresia in normal & steroid induced PCO rat ovaries.

BACKGROUND: In this study, we investigated the effect of hyperbaric oxygen therapy (HBOT) on the morphology of estradiol valerate (EV) induced polycystic ovary (PCO) to find a new treatment modality for improvement of PCO. METHODS: The rats were divided into four groups. Group1, control; group 2, PCO group; group 3, PCO with HBOT group and group 4, normal ovary with HBOT. PCO was induced by a single intramuscular injection of 4 mg EV in adult cycling rats. Other rats with normal ovaries had oil injection as placebo. HBOT was applied to third and fourth groups for six weeks. Histopathologic evaluation of ovaries of all groups were performed & compared. RESULTS: Six weeks of HBOT was resulted in increase in follicular atresia, decrease in the number of primary, secondary, tertiary follicles and decrease in the number of fresh corpus luteum in normal rat ovary. HBOT on polycystic rat ovary, resulted in significant increase in atretic follicles which were already present. CONCLUSIONS: HBOT of six weeks itself, changed ovarian morphology in favor of atresia both in PCO group and control group. This result of aggravated follicular atresia after HBOT on EV induced PCO may be due to long-term exposure in our protocol which with this state seems to be inapplicable in the improvement of PCO morphology.

PAPP-A levels of late pregnancy in preeclampsia and HELLP syndrome.

PURPOSE: To determine the relationship between pregnancy-associated plasma protein-A (PAPP-A) levels and preeclampsia and HELLP syndrome at last trimester and to investigate if the severity of preeclampsia would be associated with PAPP-A levels. METHODS: Four groups were constructed; mild-preeclampsia group consisted of 19 women, severe-preeclampsia group 17, HELLP group 5 and control group 32 women. All groups were matched strictly for gestational age at last trimester. Maternal blood samples for PAPP-A were collected as soon as the patients were diagnosed as preeclampsia or HELLP syndrome at last trimester and compared. RESULTS: Mean ages of participants, parity, gestational week, and fetal weights were similar. Mean PAPP-A levels were significantly higher in preeclampsia and HELLP groups compared to control group. PAPP-A levels were not different among mild-severe preeclampsia and HELLP groups. There was significant, positive and strong correlation between gestational age and PAPP-A level and also between fetal weight and PAPP-A levels (correlation coefficents = 0.83 and 0.78 respectively). CONCLUSION: PAPP-A level at last trimester increases in all mild-severe preeclampsia and HELLP syndrome, but is not predictive for severity of preeclampsia or HELLP syndrome.

Remission of endometriosis by hyperbaric oxygen treatment in rats.

We designed this prospective, randomized controlled animal study to determine the effects of hyperbaric oxygen (HBO) on experimentally induced endometriosis in a rat model. Surgical induction of endometriosis was performed in 40, nonpregnant, female, Wistar-Albino rats at the Experimental Medicine Research Center of Istanbul University (DETAE). Four weeks later, the first and second laparotomies for volume measurement and peritoneal fluid (PF) collection were performed, and the rats were divided randomly into the study and control groups. The study group was exposed to HBO treatment for 6 weeks. Then, a third laparotomy was performed on all of the rats. The volume, histopathologic scores, Ki-67 labeling of the endometriotic implants, and the levels of tumor necrosis factor-α (TNF-α) in the PF were measured. The mean volume of the endometriotic implants in the study group was significantly lower than that of the control group at the end of the study (57.4 ± 12.5 vs 94.6 ± 17.2 mm(3)). The mean histopathological scores (1.60 ± 0.50 vs 2.42 ± 0.51), Ki-67 immunohistochemical scores (1.50 ± 0.51 vs 2.37 ± 0.49) of the endometriotic implants, and the TNF-α levels (5.33 ± 1.02 vs 8.16 ± 1.76 pg/mL) were significantly lower in the study group than in the control group. Hyperbaric oxygen treatment for 2 hours a day for 6 weeks resulted in significant remission of endometriosis in rats.

Craniorachischisis with a variant of pentalogy of Cantrell, with lung extrophy.

A case of cranioraschischisis including incomplete pentalogy of Cantrell (PC) is described. The female fetus had a large omphalocele with evisceration of the heart, left lung, liver, stomach, and intestines accompanying anencephaly, cervical, thoracal lumbar, spina bifida. The fetus had ectopia cordis and diaphragmatic agenesia with an intact sternum. We present a case of a neonate with the stigmata for PC with the exception of a sternal defect. A literature review is also included. Sonographers should check for ventral and dorsal anomalies with PC because they may occur simultaneously.

Hyperthyroidism: a risk factor for female sexual dysfunction.

INTRODUCTION: Hyperthyroidism is a common hormonal disorder in women that may cause female sexual dysfunction (FSD). AIM: To assess sexual function in women with hyperthyroidism. METHODS: A total of 40 women with clinical hyperthyroidism and 40 age-matched voluntary healthy women controls were included in the study. All the subjects were evaluated with a detailed medical and sexual history, including a Female Sexual Function Index (FSFI) questionnaire for sexual status and the Beck Depression Inventory (BDI) for psychiatric assessment. MAIN OUTCOMES MEASURES: The levels of serum thyroid-stimulating hormone (TSH), thyroid hormones, sex hormone binding globulin (SHBG), total testosterone (tT), free testosterone (fT), prolactin, estradiol, follicle-stimulating hormone, and luteinizing hormone were measured. RESULTS: The mean total FSFI scores were 24.2 ± 9.96 in the hyperthyroidic group and 29 ± 10.4 in the control group (P < 0.0001). Desire (P < 0.040), arousal (P < 0.0001), lubrication (P < 0.0001), orgasm (P < 0.0001), satisfaction (P < 0.0001), and pain (P < 0.007) domain scores were also significantly lower in women with hyperthyroidism. The mean BDI score for hyperthyroidic patients was significantly greater than the score for the control group (P < 0.0001). The mean SHBG level in the hyperthyroidic group was found to be significantly higher than the level in the controls (P < 0.0001), whereas the mean fT level in the hyperthyroidic group was lower than in the control group (P < 0.0001). The FSFI score showed a significant negative correlation with the serum SHBG (r = -0.309, P = 0.005), free triiodothyronine (r = -0.353, P = 0.006) and free tetraiodothyronine (r = -0.305, P = 0.018) levels, BDI scores (r = -0.802, P = 0.0001) and positive correlation with tT (r = 0.284, P = 0.011), fT (r = 0.407, P = 0.001), and TSH (r = 0.615, P = 0.0001) levels. CONCLUSIONS: A significant percentage of women with clinical hyperthyroidism had sexual dysfunction. Increased depressive symptoms, increased SHBG level, and decreased fT levels were all found to be associated with FSD in clinical hyperthyroidism.

Late pregnancy associated plasma protein A levels decrease in preterm labor.

OBJECTIVE: The purpose of the present study is to evaluate late, 'at admission', Pregnancy-associated plasma protein-A (PAPP-A) levels as a predictor of preterm birth in women with complaints of preterm labor or preterm painful contractions. METHODS: Prospective cohort study of singleton gestations, 23-37 weeks, and symptoms of preterm labor. Primary end point was delivery < 37 weeks. Predictive PAPP-A values were calculated both for preterm delivery and threatened preterm delivery on receiver operator curve. RESULTS: In all, 41 women (38.3%) delivered before 37 weeks (Group 1); 32 women (30.7%) had symptoms of preterm labor but did not deliver preterm (Group 2); 31 women (29.7%) delivered term (Group 3, control). Mean PAPP-A levels in preterm-labor and its matched control were 33.4 ± 19.9 and 52.5 ± 25.4 mIU/ml, respectively, and difference was statistically significant (p = 0.003). Mean PAPP-A level in threatened preterm labor group was 47.6 ± 25.3 mIU/ml and difference was significant compared to preterm-labor, but not significant compared to control group (p = 0.028 and p = 0.74, respectively). CONCLUSION: Late PAPP-A levels decreased in preterm labor, levels < 29.8 mIU/ml was associated with increased risk for preterm birth, supporting active management whereas cutoff value of 33.6 mIU/ml is useful for discrimination of preterm birth from threatened preterm birth reaching to term.

Factors affecting the accuracy of ultrasonographical fetal weight estimation in twin pregnancies.

OBJECTIVE: To determine the factors affecting the accuracy of ultrasonographic weight estimation in twins. METHODS: 152 sets of twins delivered vaginally, were included. Effects of fetal weights, inter-twin weight discordance, chorionicity, early rupture of membranes, intrauterine growth restriction, and presentations of twins on errors of estimated fetal weights were evaluated. The primary measures of estimated fetal weight accuracy compared were mean-percentage-error and the standart deviation (SD) of percentage errors. RESULTS: Mean percentage errors for the first fetus (8.13 ± 6.82) and the second fetus (8.07 ± 6.88) were similar (p = 0.64). Random errors of both fetuses were also similar (p = 0.78). If one of the fetuses had IUGR, the percentage error and also the random error of that fetus would increase significantly. Different presentations and fetal gender combinations were similar for both types of errors of fetal weight estimation. A weak negative lineer relationship was found between the weight of the first fetus and its percentage error (r = -0.27, p = 0.04). A similar relation was present between the weight and percentage error of the second fetus (r = -0.29, p = 0.03). Percentage errors and also random errors of both fetuses were significantly higher if severe discordance was present between twins (p = 0.01 and p = 0.02, respectively). CONCLUSIONS: IUGR, fetal weights, and inter-twin discordence are the factors affecting the accuracy of weight estimation by ultrasonography.

Hyperreactio luteinalis with preeclampsia.

Hyperreactio luteinalis (HL) is a condition associated with bilateral and, in rare cases, unilateral ovarian enlargement due to theca lutein cysts. HL is a benign condition, usually found incidentally at cesarean section, which can appear anaplastic and lead to unnecessary ovarian resection. A 24-year-old woman with 35 weeks of gestation attended with bilaterally enlarged ovaries. She had preeclampsia and preterm contractions. Due to breech presentation of baby and nulliparity and possible severe preeclampsia, she delivered by cesarean section. The ovaries had an anaplastic appearance and a biopsy was taken during cesarean section. Pathology revealed multiple benign theca lutein cysts. There are 51 reported cases of HL associated with a normal pregnancy in the literature. It is estimated that approximately 60% of the cases of HL is not associated with trophoblastic disease and occurs with normal singleton pregnancy. Only three of them were found to be associated with preeclampsia and this is the fourth case. HL may help explain the underlying cause of preeclampsia in these cases. There are multiple benign ovarian lesions in HL, which can mimic ovarian neoplasms. Accordingly, it is important to exclude these from the differential diagnosis via a wedge biopsy and frozen section to avoid unnecessary surgical excision.

Sexual dysfunction in women with clinical hypothyroidism and subclinical hypothyroidism.

INTRODUCTION: Hypothyroidism is a common hormonal disorder in women that may affect the phases of female sexual function. AIM: To investigate female sexual function in patients with clinic hypothyroidism and subclinic hypothyroidism. METHODS: A total of 25 women with clinic hypothyroidism (group 4), 25 women with subclinic hypothyroidism [thyroid stimulating hormone (TSH) value 10 mU/L (group 3)], and 20 age matched voluntary healthy women controls (group 1) were included in the study. All the subjects were evaluated with a detailed medical and sexual history, including a female sexual function index (FSFI) questionnaire for sexual status and the Beck Depression Inventory for psychiatric assessment. MAIN OUTCOME MEASURES: The levels of serum TSH, thyroid hormones, prolactin (PRL), free testosterone, estradiol, follicle-stimulating hormone, luteinizing hormone, lipid profile, and blood glucose were measured. RESULTS: Female sexual dysfunction (FSD) was diagnosed in 14 of 25 patients (56%) in group 4, in 6 of 11 patients (54.6%) in group 3, in 2 of 14 patients (14.6%) in group 2, and while only 3 of 20 the control group of women (15%) had FSD (P = 0.006). The mean total FSFI scores were 23.9 in the group 4, 26.03 in the group 3, 29.2 in the group 2, and 32.30 in the control group (P < 0.0001). The mean BDI score for clinic hypothyroidic patients was significantly greater than the scores for the control group and for the group 2 (P = 0.017 and P = 0.043, respectively). The mean PRL levels for patients in group 4 and group 3 were found to be significantly higher than the level for controls (P < 0.0001), whereas other serum hormone levels were not different among groups. CONCLUSIONS: A significant percent of women with clinic hypothyroidism and subclinic hypothyroidism with TSH values >10 mU/L had sexual dysfunction. Hyperprolactinemia, hyperlipidemia, and depression were associated with FSD in clinic hypothyroidism. Different than clinic hypothyroidism depression was not associated with FSD in subclinic hypothyroidism with TSH values >10 mU/L.

Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: a randomised, open-label study.

OBJECTIVE: To compare the effectiveness and side effects of cabergoline with bromocriptine for the symptomatic treatment of cyclic mastalgia as a part of the premenstrual syndrome. STUDY DESIGN: 140 women with premenstrual mastalgia were enrolled in this randomised, open-label trial. Two groups were created (bromocriptine and cabergoline) and consisted of 61 and 67 patients respectively at the end of trial. Bromocriptine was administered 5 mg daily during second half of the menstrual cycle. Cabergoline was administered 0.5 mg weekly during the second half of the cycle. Relief of pain was evaluated using a visual analog scale (VAS). The mean percentage decrease in score for all patients in each group was calculated. A 50% or greater decrease at the end of the third month from the basal VAS score was accepted as a positive response to drug therapy. Data regarding side effects were collected systematically with review of a symptom diary. RESULTS: The positive response rates to treatment were similar (bromocriptine 66.6% and cabergoline 68.4%). The pain reduction rates for each month were also similar. Moreover, the pain reduction rate was maximum in the second month of treatment for both groups. Vomiting (28%), nausea (39%) and headaches (23%) recorded in the bromocriptine group were significantly more frequent than vomiting (4.5%), nausea (20.9%) and headache (6%) recorded in the cabergoline group (p=0.023, p=0.001, p=0.006 respectively). A difference in the rate of dizziness was not statistically significant (26.4% vs. 14.9%). There was no correlation between the baseline breast pain score and prolactin level but post-treatment pain reduction was well correlated with prolactin level. CONCLUSIONS: Cabergoline is as effective as bromocriptine for the treatment of cyclic mastalgia but has minimal side effects compared to bromocriptine.

An endometriotic vault fistula presenting with monthly bleeding after hysterectomy.

INTRODUCTION: The aetiology of endometriosis remains unknown. The clinical presentation of endometriosis can be highly variable, occurring in numerous potential locations outside the abdomen and associated with distinct complaints. Recurrence is common, though we present a very rare case of recurrence and complication. CASE PRESENTATION: A 42-year-old caucasian woman was admitted to our unite with monthly vaginal bleeding lasting 3-5 days, beginning from 6 months after previous hysterectomy and right salpingo-oophorectomy surgery for myoma and endometrioma. We suspected of endometrioma of the left ovarium upon transvaginal ultrasonography, and diagnosed vault fistula from the endometriosis cyst to the vagina. We re-operated the patient using Pfannenstiel incision, and performed left-oophorectomy and fistula repairment. The Pouch of Douglas was obliterated and many bowel adhesions were present, indicating a stage IV endometriosis. According to our assessment, stage IV endometriosis had been present in the previous surgery. CONCLUSIONS: Considering that the short-term endometriosis recurrence is higher in premenopausal age and in advanced stage of endometriosis, bilateral oophorectomy together with hysterectomy may be a better operational choice for these patients.

Mid-trimester amniotic fluid angiogenin, lactate dehydrogenase and fibronectin in the prediction of preterm delivery.

OBJECTIVE: Our purpose was to compare angiogenin, lactate dehydrogenase (LDH) and fibronectin levels in mid-trimester amniotic fluid of patients with preterm and term deliveries and to find out their predictive values for preterm birth. STUDY DESIGN: A prospective cohort study was conducted in 55 pregnancies with singleton gestations that underwent amniocentesis at 15-20 weeks for standard genetic indications. Amniotic fluid angiogenin, lactate dehydrogenase and fibronectin levels were measured by enzyme-linked immunosorbent assay (ELISA), radial immundiffusion technic and automated analyzer, respectively. RESULTS: Five patients delivered preterm, five developed signs or symptoms of threatened preterm labor and 45 had term delivery after an uneventful pregnancy. Demographic data were not significantly different. Amniotic fluid angiogenin and lactate dehydrogenase levels were significantly higher in patients with preterm than term deliveries (P<0.001 and 0.02, respectively). Receiver-operator characteristic curve analysis showed that the amniotic fluid angiogenin had the best screening efficiency in predicting preterm delivery. An angiogenin level of 35ng/ml was the optimal cut-off value for the prediction of preterm delivery, with a sensitivity of 100% and specificity of 91%. CONCLUSION: Second-trimester angiogenin is found to be quite effective in the prediction of preterm delivery. Preexisting intrauterine ischemia may be an important risk factor for preterm delivery and already be present in the early mid-trimester.