The Relationship between First Trimester 25-Hydroxyvitamin D3 Levels and Second Trimester Femur Length and Their Effects on Birth Weight and Length at Birth: A Preliminary Study.

OBJECTIVE: The main goal of our study was to assess relationships between first trimester 25-hydroxyvitamin D3 levels and infant birthweight and length at birth. MATERIALS AND METHODS: We conducted a study over our medical records of 154 live-term births at Acibadem Atakent Hospital, Istanbul, Turkey. Subjects were classified into five independent groups. RESULTS: We retrospectively reviewed a total of 154 live birth records. They took vitamin D3 supplement 1000 U/day. We classified the serum vitamin D levels into 5 groups by concentration. Group 1 comprised serum vitamin D levels <10 ng/ml (n = 41); group 2 comprised serum Vitamin D levels between >10-16 ng/ml (n = 33); group 3 comprised serum vitamin D levels >16-20 ng/ml (n = 26); group 4 vitamin D level between >20-30 ng/ml (n = 33) and group 5 comprised vitamin D levels >30 ng/ml. The femurs of infants were found to be longer between the groups, although the differences were not significant (p=0.054). There was also a statistically significant difference in the neonatal birth weight (p=0.048). CONCLUSION: We observed associations between low and high maternal 25-hydroxyvitamin D3 levels and fetal growth at birth weight but no difference in birth length. We conclude that we always need to conduct further research to be able to predict the effects of vitamin D deficiency.

Laparoscopic Management of Heterotopic Istmocornual Pregnancy: A Different Technique.

STUDY OBJECTIVE: To present a modified technique for laparoscopic cornual resection for the surgical treatment of heterotopic istmocornual pregnancy. DESIGN: A step-by-step explanation of the surgery using video (Canadian Task Force Classification III-c). SETTING: Heterotopic pregnancy is the coexistence of pregnancy in both the intrauterine and extrauterine sides. The incidence is 1 in 30 000 in spontaneous pregnancies; however, the incidence increased to 1 in 100 to 1 in 500 pregnancies with the increasing number of artificial reproductive technologies [1,2]. Although management is controversial, there are 2 main approaches classified as surgical and nonsurgical. The administration of potassium chloride, methotrexate, and/or hyperosmolar glucose is a nonsurgical intervention; however, there are some limitations such as systemic side effects and the possible adverse effect on a live fetus [1-3]. For this reason, surgical intervention involving cornual resection is the main treatment option. CASE REPORT: A 32-year-old patient was admitted to our clinic with sudden-onset pain at the left groin. She was at the 11th week of gestation. She had a diagnosis of infertility for 7 years, and she became pregnant after an in vitro fertilization cycle. At sonographic examination, 2 gestational sacs were detected, 1 with a live fetus settled into the uterus and the second (20-mm length) on the left cornual side without a yolk sac and embryo and the left adnexa accompanied with coagulated blood. Immediate laparoscopic surgery was planned. At the laparoscopic exploration, left istmocornual pregnancy that was ruptured and bleeding were observed. We performed a modified technique for laparoscopic cornual resection in which the uterine corn was tightened with the noose twice, and the corn was sutured circularly to avoid excessive bleeding. Initially, the mesosalpinx was coagulated and transected with bipolar energy. Afterward, the uterine corn was tightened with the noose twice, and the fallopian tube was removed. To reduce the bleeding during remnant cornual tissue extraction, a permanent 0 monofilament suture was passed deep into the myometrium and tightened to achieve better hemostasis. Then, the remnant cornual tissue was extracted with harmonic scissors, and the uterine wound was repaired with continuous suture to reduce the risk of uterine rupture during the ongoing pregnancy. Depot progesterone was administered just before the surgery and the day after. She was discharged on the first postoperative day. At the follow-up, she did not experience any problems during pregnancy, and she was delivered with cesarean section at 39 weeks' gestation. CONCLUSION: In conclusion, laparoscopic surgery is a safe and feasible option for the treatment of heterotopic pregnancy, and control of bleeding can be achieved better with our modified technique.

Single-Port Total Laparoscopic Hysterectomy in a Patient With Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To present the feasibility of single-port laparoscopic surgery at patients with deep infiltrating endometriosis. DESIGN: Step by step explanation of the surgery using videos (Canadian Task Force classification III-c). SETTING: Single-port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. The goals of single-port laparoscopic surgery is to further enhance the cosmetic benefits of minimally invasive surgery and minimize the potential risk and morbidity associated with multiport surgery [1,2]. This procedure is not without challenges, however, such as instrument crowding and clashing, ergonomic difficulties, loss of instrument triangulation, and the need for advanced laparoscopic skills [1,2]. Despite these challenges, technical advances in optics and instrumentation have led to the widespread use of single-port laparoscopic surgery to treat such gynecologic disorders as endometriosis, uterine myomas, and cancers [2,3]. INTERVENTIONS: A 42-year-old woman was admitted to our clinic with a complaint of chronic pelvic pain dysmenorrhea and deep dyspareunia. Her medical history revealed a cesarean section delivery and a diagnosis of endometriosis. Despite treatment of her endometriosis with dienogest, there has been no decline at her complaints. Ultrasound examination performed at admission revealed a 6 × 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules. Although all treatment options were explained and discussed and laparoscopic excision of right ovarian endometrioma was recommended, the patient strongly desired removal of the uterus and the ovaries to avoid recurrence of endometriosis and related complaints. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were planned. Under general anesthesia and endotracheal intubation, the patient was placed in low lithotomy position with the arms tucked. An orogastric tube and a Foley catheter were placed. Abdominal access was performed following an open Hasson technique with a 2.0- to 2.5-cm vertical umbilical incision and a 4-channel (with two 10-mm and two 5-mm channels) access port was placed into the peritoneal cavity. On pelvic examination, a 6 × 6-cm right ovarian endometrioma adherent to the pelvic sidewall was detected, along with severe adhesions on the left side between the left adnex and the pelvic sidewall. The uterus was normal. The adhesion on the left side was released using a Harmonic scalpel (Ethicon Endosurgery, Cinncinnati, OH). The pelvic sidewall peritoneum was opened, and the ureters were identified and isolated at the pelvic brim and followed toward the true pelvis. The internal iliac artery, uterine and obliterated umbilical artery, and infundibulopelvic ligament were dissected and identified. The paravesical, pararectal, and rectouterine spaces were opened. Deep infiltrating endometriosis implants on the right side located in the uterosacral ligment and pararectal space were dissected and excised. After restoration of pelvic anatomy, hysterectomy and bilateral salpingo-oophorectomy were performed. The vaginal cuff was closed with intracorporeal knots. The patient was discharged on postoperative day 1, and reported no problems at follow-up. CONCLUSION: Single-port laparoscopic hysterectomy appears to be a safe and feasible option in patients with deep infiltrating endometriosis, especially when performed by well-experienced surgeons.