The importance of blood-count-derived inflammatory markers in predicting methotrexate success in patients with tubal ectopic pregnancy.

OBJECTIVE: To investigate the systemic immune-inflammation index (SII) and neutrophil-to-lymphocyte ratio (NLR) in predicting a successful methotrexate response in tubal ectopic pregnancy (TEP). METHODS: Women treated for TEP at a tertiary hospital between 2017 and 2021 were retrospectively reviewed. A total of 502 (100%) eligible patients who received methotrexate were included and divided into two groups based on whether or not they were successfully treated with methotrexate alone. Inflammatory parameters derived from the patients' hemograms at hospital admission were compared. RESULTS: In total, 434 (86.4%) patients were successfully treated with methotrexate alone (Group 1), while 68 (13.6%) patients underwent surgery after methotrexate failure (Group 2). Median neutrophil count, NLR, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, SII, largest ectopic mass diameter, and ß-human chorionic gonadotropin (ß-hCG) were significantly lower, whereas median lymphocyte and platelet counts were significantly higher in Group 1. According to the receiver operating characteristic analysis performed for the discriminatory power of NLR, ß-hCG, and SII for methotrexate response, the area under the curve values were 0.742, 0.730, and 0.699, respectively. CONCLUSION: Low NLR and SII are associated with methotrexate success and could be used to refine decision making regarding ß-hCG for predicting successful response to methotrexate in patients with TEP.

The use of late preterm antenatal corticosteroids in women with gestational diabetes : a puzzle worth solving.

BACKGROUND: To investigate the association between late preterm antenatal corticosteroid treatment and outcome in late preterm neonates born to mothers with gestational diabetes mellitus, METHODS: All patients with gestational diabetes mellitus who had a late preterm delivery at Etlik Lady Zübeyde Hospital between 2017 and 2021 were included. Women who met the inclusion criteria and were not given antenatal corticosteroid treatment during current pregnancy before 34 0/7 weeks of gestation were divided into two groups according to whether or not they received late preterm antenatal corticosteroid treatment. The two groups were compared in terms of adverse neonatal complications. The main outcomes were composite respiratory outcome and composite neonatal outcome. Logistic regression analysis was used to determine additional potential predictors of neonatal outcome. RESULTS: This retrospective cohort study included a total of 400 participants with gestational diabetes mellitus who had a late preterm delivery within the study period. Of these women, 196 (49%) received late preterm antenatal corticosteroid treatment. Main outcomes showed no difference. Decreasing gestational age at birth was identified as an independent risk factor predicting both composite respiratory outcome and composite neonatal outcome in multivariate logistic regression analysis. CONCLUSIONS: Antenatal corticosteroid treatment at or after 34 0/7 weeks of gestation in women with gestational diabetes mellitus who had a late preterm delivery was not associated with improvement in adverse neonatal outcomes. Decreasing gestational age at birth was the only independent risk factor predicting composite neonatal and composite respiratory outcomes.

Evaluation of systemic immune-inflammation index for predicting late-onset fetal growth restriction.

INTRODUCTION: To determine a cut-off value for systemic immune-inflammation index (SII) (neutrophil × platelet/lymphocyte) in the prediction of fetal growth restriction (FGR). MATERIALS AND METHODS: This case-control study was conducted retrospectively at the Obstetrics-Gynecology and Perinatology Clinics of Etlik Zubeyde Hanim Women's Health Education and Training Hospital. Singleton pregnant women with late-onset FGR who were followed up in outpatient clinics or hospitalized and whose pregnancy resulted at our hospital were included in the study group (group I). Healthy early and full-term singleton pregnant women with spontaneous labor who were followed up in the same hospital and whose pregnancy resulted at the same hospital were included in the control group (group II). Receiver-operating characteristic curves were used to assess the performance of SII value in predicting FGR. RESULTS: We recruited 79 cases (pregnant with late-onset fetal growth restriction) and 79 controls (healthy pregnant), matched for age, body mass index, and parity. ΔSII was statistically significantly higher in the pregnant with late-onset FGR compared with healthy pregnant (123 vs - 65; p = 0.039). The values in ROC curves with the best balance of sensitivity/specificity were > 152 109/L (49% sensitivity, 70% specificity) and > 586 109/L (27% sensitivity, 90% specificity) for late-onset FGR. DISCUSSION: Higher ΔSII levels in maternal blood indicate an inflammatory process causing FGR. The cut-off value for ΔSII (> 586 109/L) at 90% specificity can be used as a screening test. In the presence of ΔSII levels > 586 109/L (27% sensitivity and 90% specificity), the physicians should be more cautious about risk for FGR. Therefore, pregnant women at risk for FGR should be checked more frequently and monitored closely. However, further studies are needed to confirm our findings.

Importance of hemogram parameters for predicting uterine scar dehiscence

Objective: The pathophysiology of uterine scar dehiscence is not yet clear. The aim of this study was to investigate whether preoperative hemogram parameters can be used as predictive markers of uterine scar dehiscence, thus improving prediction and contributing to management of repeat Cesarean section. Material and Methods: Between 2015 and 2020, 36670 (47.6%) cesarean sections were delivered in our hospital and 16943 of them had a previous Cesarean section. All cases of uterine scar rupture detected during Cesarean section were identified, and a total of 40 patients were included after excluding cases with impairment of the systemic inflammatory response (SIR). Controls consisted of 40 randomly selected, age-and body mass index (BMI)-matched patients, and the groups were compared. Results: Age, BMI, and gravidity were similar (p>0.05). Although the gestational week and Apgar scores were similar between the groups (p>0.05), the birth weight amongst controls was significantly higher than the uterine dehiscence group (p=0.028). Platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, and other hemogram values were similar in both groups (p>0.05). Mean platelet volume (MPV) in the control group was significantly higher than in the uterine rupture group (p=0.049). Regression analysis found no significant result between hemogram parameters, birth weight, and dehiscence. Conclusion: In this study, which set out to identify predictors of the risk of uterine scar dehiscence with SIR parameters, only the MPV value was lower in the dehiscence group.

Do the change in ß-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX?

AIM: The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in ß-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen. METHOD: A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in ß-hCG values compared in both groups. RESULTS: Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial ß-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of ß-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV). CONCLUSION: The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in ß-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.

Short-term Reproductive Outcomes of Nulliparous Women with Previous Ectopic Pregnancy.

OBJECTIVE: To determine the characteristics and subsequent pregnancy outcomes in patients with a previous ectopic pregnancy (EP). STUDY DESIGN: Descriptive-cross sectional study. PLACE AND DURATION OF STUDY: Department of Obstetrics-Gynaecology, Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey, between January 2014 and December December 2018. METHODOLOGY: The data of nulliparous patients diagnosed with tubal ectopic pregnancy (EP) was analysed retrospectively. Reproductive outcomes within the first two years after ectopic pregnancy diagnosis were used as "short-term" reproductive outcomes. Their EP treatment and pregnancy outcome were determined. RESULTS: Expectant management was chosen in 5.8% of the patients, while the surgical intervention was 32.3%. Medical therapy involving methotrexate (MTX) was given to the remaining patients (61.9%). The tubal rupture was confirmed in 12% of the cases that received MTX. In the 2-year follow-up period after the ectopic event, the most common outcome of the subsequent pregnancies was a live birth (47.7%). Recurrent EP occurred in 4.6%. CONCLUSION: The subsequent short-term pregnancy outcomes in this study were not related to the chosen treatment modality. KEY WORDS: Ectopic pregnancy, Nulliparity, Reproductive outcomes, Treatment modalities, Expectant management.

Increased fetal epicardial fat thickness: A reflecting finding for GDM and perinatal outcomes.

OBJECTIVE: To study the value of fetal epicardial fat thickness (EFT) in gestational diabetes mellitus in the third trimester of pregnancy and its relationship with clinical parameters and perinatal outcomes. METHODS: A total of 80 participants, including 40 with diagnosed GDM and 40 healthy pregnant women, were included in the study. Demographic data were obtained from medical records. Sonographic examinations were performed, such as amniotic fluid value, fetal biometric measurements, and Doppler parameters of the umbilical artery. Fetal EFT values were measured at the free wall of the right ventricle using a reference line with echocardiographic methods. Correlation tests were performed to evaluate the relationship between fetal EFT and clinical and perinatal parameters. p < .05 were interpreted as statistically significant. RESULTS: The fetal EFT value was statistically higher in the GDM group than in the control group (p: .000). Spearman and Pearson correlation tests revealed statistically significant but weak positive correlations between fetal EFT value, 1-h 100-g OGTT, birth weight, and BMI (r: .198, p: .047; r: .395, p: .012; r: .360, p: .042, respectively). The optimal fetal EFT threshold for predicting GDM disease was found as 1.55 mm, with a specificity of 74.4% and sensitivity of 75.0%. Statistically significant differences between the two groups in umbilical artery Doppler resistance index (RI), pulsatility index (PI), and systolic/diastolic ratio (S/D) were not found (p: .337; p: .503; p: .155;). BMI and amniotic fluid volume were higher in the GDM group compared to the control group (p: .009; p < .01). CONCLUSION: This study demonstrated that increased fetal EFT may occur as a reflection of changes in glucose metabolism in intrauterine life. Future studies with larger series, including the study of neonatal metabolic parameters, will contribute to the understanding of the importance of fetal EFT in determining the metabolic status of the fetus.

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

PURPOSE: The purpose of this study was to compare the outcomes of interval debulking surgery after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC). METHODS: A total of 292 patients with IIIC and IV disease stages, who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared. RESULTS: The mean patient age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The survival rate of patients who received optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who received suboptimal cytoreductive surgery (p<0.01 and p<0.01, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS. CONCLUSIONS: There was no definitive evidence regarding whether NAC/IDS increases survival rates compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.

Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: incidence, risk factors and management.

INTRODUCTION: Chylous ascites is a rare form of ascites that results from accumulated lymph fluid in the peritoneal cavity caused by blocked or disrupted lymph flow through the major lymphatic channels. In the present study, our aim was to analyze the incidence, risk factors, diagnostic evaluation and management of chylous ascites after lymphadenectomy in gynecologic malignancies. METHODS: A total of 458 patients who had undergone staging surgery for gynecologic malignancies at our institution between January 2010 and December 2013 were retrospectively reviewed. After the exclusion criteria were applied, 399 patients were divided into 2 groups based on the presence (n = 36) or absence (n = 363) of chylous ascites. RESULTS: Among the 399 patients, 36 (9%) developed chylous ascites. The median time to onset was 4 days (range, 2-7 days). The analysis of the various features of lymphadenectomy showed that the number of para-aortic lymph nodes (PALNs) removed was significantly greater in the patients with chylous ascites (p < 0.001). A cut-off value of >14 PALNs was a good predictor of chylous ascites. In all patients, chylous ascites resolved with conservative management. CONCLUSIONS: Postoperative chylous ascites was strongly associated with the number of harvested PALNs. According to our findings, we suggest that conservative treatment should be the first step in managing patients with chylous ascites. Using an abdominal drain after surgery seems to be an effective diagnostic tool and treatment method for chylous ascites.

Lymphovascular space invasion and positive pelvic lymph nodes are independent risk factors for para-aortic nodal metastasis in endometrioid endometrial cancer.

OBJECTIVE: Para-aortic lymph node dissemination in endometrioid endometrial cancer is uncommon, and systematic para-aortic lymph node dissection increases morbidity. The purpose of this study was to identify a subgroup of endometrioid endometrial cancer patients who did not require para-aortic lymphadenectomy. STUDY DESIGN: All patients who had undergone surgery for endometrioid endometrial cancer between 1 January 1995 and 31 December 2012 were retrospectively reviewed. Patients with higher risk factors for nodal metastasis and inadequate lymphadenectomy were excluded. Para-aortic lymph node dissemination was defined as nodal metastasis when pelvic and para-aortic lymph node dissection was performed, when para-aortic lymph node recurrence occurred after negative para-aortic lymph node dissection or when para-aortic lymph node dissection was not performed. Multivariate logistic regression models were used to identify the pathological features as predictors for para-aortic lymphatic dissemination. RESULTS: A total of 827 patients were assessed, 516 (62.4%) of whom underwent pelvic and para-aortic lymph node dissection. Sixty-seven (13%) patients (37 with only pelvic, 26 with pelvic and para-aortic, and 4 with only para-aortic metastasis) had positive lymph nodes in the pelvic and para-aortic lymph node dissection group. Multivariate analysis confirmed positive pelvic nodes (odds ratio 20.58; p<0.001) and lymphovascular space invasion (odds ratio 8.10; p=0.022) as independent predictors of para-aortic lymphatic dissemination. When these two factors were absent (in 83% of patients), the predicted probability of para-aortic lymph node metastasis was 0.1%. CONCLUSION: Positive pelvic nodes and lymphovascular space invasion are highly associated with para-aortic lymph node metastasis. These markers may be useful for identifying those patients who require para-aortic lymph node dissection.