Evaluation of etiology, characteristics, and treatment of patients with vesicovaginal fistula observed in rural Africa.

OBJECTIVE: In this study, we aimed to evaluate the etiology, characteristics, and treatment of patients with diagnosis of vesicovaginal fistula (VVF) due to labor in rural Africa following surgery in a hospital with western standards according to the current literature. METHODS: In this retrospective large case series, 56 patients undergoing surgery due to prediagnosis of VVF and then followed-up regularly in Nyala-Sudan Turkey Training and Research Hospital between December 2018 and February 2019 were evaluated. The information related to the ages, mode, and the number of deliveries, previous histories of fistula repair surgery, postoperative success and complication rates were gathered. RESULTS: The absence of urine from the vagina during the examination with methylene blue was defined as success. The overall success rate was 84.3 %. The vaginal route was most commonly preferred for fistula repair surgery and its success rate and efficiency were found to be higher. In addition, a low complication rate was observed as 3.9 %. A higher rate of association was observed between Female Genital Mutilation/Cutting (FMG/C) and fistula. Especially FGM/C type 3 was frequently seen with a rate of 61.7 %. This type of FGM/C was observed in all patients undergoing reoperation. The main causes of recurrence of fistula were vaginal delivery within 6 months of repair or presence of multiple fistulas at diagnosis. CONCLUSIONS: The surgery and follow-up process should be individualized after this examination based on the condition, clinical picture of the patient and surgeon's experience. Additionally worldwide steps should be taken to prevent FGM/C as it is associated with many undesired outcomes including VVF.

Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses.

BACKGROUND: Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth. METHODS: We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134. FINDINGS: We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 µmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 µmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 µmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001). INTERPRETATION: The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 µmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery. FUNDING: Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.

Modified abdominal packing method in "near miss" patients with postpartum hemorrhages.

OBJECTIVE: To describe a more effective abdominal packing method in patients with disseminated intravascular coagulation following peripartum hysterectomy due to postpartum hemorrhage (PPH). MATERIALS AND METHODS: The present retrospective and descriptive study was conducted to document six cases with refractory pelvic bleeding who underwent a second surgery for PPH between January 2016 and December 2017 at Istanbul Zeynep Kamil Woman and Children Diseases Training and Research Hospital. RESULTS: Karateke packing was performed to control intra-abdominal massive hemorrhages of five women who were referred to our clinic due to PPH who had undergone peripartum hysterectomy and hypogastric artery ligation but hemostasis could not be provided. In addition, a case of hypovolemic shock due to placenta percreta rupture in a woman who had also undergone an emergency hysterectomy and hypogastric artery ligation, which had failed. Hemostasis was provided in all patients. No method-related complication developed. CONCLUSION: Karateke packing is a very easy method to perform, it is more effective than the classic abdominal packing technique, with a low complication rate, and most importantly, life-saving in patients undergoing a peripartum hysterectomy due to PPH and thereafter experiencing diffuse hemorrhage.

Effect of vaginal washing before intravaginal dinoprostone insertion for labor induction: A randomized clinical trial.

AIM: Prostaglandins have a dual action of cervical ripening and induction of uterine contraction. This study was designed to compare the effectiveness of vaginal washing just before insertion of intravaginal dinoprostone. METHODS: A randomized controlled trial was conducted at the Zeynep Kamil Women and Children's Health Training and Research Hospital. One hundred and ninety-one women with singleton, term pregnancy who underwent labor induction were randomly assigned to two groups: Group 1 consisted of 95 pregnant women with vaginal washing before intravaginal dinoprostone (Propess system for slow release system of 10 mg of dinoprostone) insertion (study group), and 96 pregnant women constituted the control group who did not undergo vaginal washing before intravaginal dinoprostone insertion. A parallel randomized controlled trial was conducted with an allocation ratio of 1:1 to compare the effectiveness of vaginal washing before intravaginal dinoprostone insertion. RESULTS: The groups had similar mean age, body mass index, gestational age, gravidity, parity and Bishop score before agent insertion (P > 0.05). Duration of dinoprostone kept intravaginally, duration from the beginning of dinoprostone insert vaginally to the active phase of labor and duration from the time of intravaginal dinoprostone insertion to delivery were significantly longer in the control group (P < 0.05). Uterine hyperstimulation rate was significantly higher in study group compared to control group (P < 0.05). Meconium passage, fetal infection and neonatal intensive care unit admission were significantly higher in the control group (P < 0.05). CONCLUSION: Vaginal washing before intravaginal dinoprostone insertion may increase Prostaglandin E2 bioavailability as we found shorter duration and better outcome of labor induction in the present study.

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.

Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach.

AIM: The aim of this study was to introduce a modified form of fertility preserving approach in cases with placenta percreta. METHODS: Eleven pregnant women with anterior placenta previa and suspected to have placenta percreta underwent cesarean section between 2015 and 2016 in Zeynep Kamil Women and Children's Health Training and Research Hospital. In all cases, following confirmation of placenta percreta diagnosis, a modified minimal invasive form of uterine preserving surgery was performed. RESULTS: During the present study period, 11 pregnant women who were confirmed to have placenta previa and placenta percreta underwent modified form of segmental resection. In all cases, modified form of segmental resection was successful except for the two cases. There were significant statistical differences between pre-postoperative hemoglobin and hematocrit levels (p = .003). There was a significant correlation between the volume of resected segment and number of transfusions (r = .760, p = .047). Postoperative blood transfusion was not needed in 4 cases. No maternal mortality or other postoperative complication was observed in any case. CONCLUSION: A modified minimal invasive form of uterine preserving surgery seems to be safe and result in more cosmetic results with minimal blood loss.

Can we predict severity of intrahepatic cholestasis of pregnancy using inflammatory markers?

OBJECTIVE: To investigate the association of inflammatory markers with severity of intrahepatic cholestasis of pregnancy (ICP). MATERIALS AND METHODS: This retrospective case-control study was conducted with 229 pregnant women, 84 with ICP, and 145 age-matched healthy pregnant women. Patients were categorized as mild ICP (<40 µmol/L) and severe ICP (≥40 µmol/L) with regard to serum bile acids. Inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), platelet-to- lymphocyte ratio (PLR) and mean platelet volume (MPV), and red blood cell distribution width (RDW) were compared between the groups. RESULTS: Patients with ICP had significantly decreased RDW and increased white blood cell counts (WBC), MPV and PLR, but no significant changes in NLR. The comparison of mild and severe cases with regard to NLR, PLR, WBC, and RDW was similar (p>0.05). MPV levels were significantly increased in severe group (p<0.05). CONCLUSION: WBC, MPV, and PLR were the inflammatory markers significantly increased, and RDW was signifantly reduced in ICP. MPV was the marker that significantly increased with the severity of disease. The use of inflammatory markers in the assessment of perinatal outcomes needs further studies.

Upper limb hemimelia in a twin pregnancy which was obtained by an ICSI and PGD in a woman with mosaic Turner's syndrome and the prognosis.

Turner's syndrome (TS) is depicted as a total or partial absence of X chromosome, and occurs in approximately 1/2200 of live born females. Generally, mosaic patients are diagnosed following karyotype analysis due to recurrent pregnancy loss, repeated in vitro fertilization (IVF) failure, and a history of malformed babies. The purpose of this case report is to show that even a selection of normal karyotype embryos can result in abnormalities for those with mosaic TS. A 32-year old patient who underwent IVF after ICSI-PGD, and was diagnosed with 45X/46XX karyotype. At the 12-week scan, one of the fetuses had an upper limb hemimelia in one arm, and feticide was applied to that fetus. The patient delivered a healthy, 2980 g female baby at the thirty-eighth week. In mosaic TS pregnancies (even those obtained by ICSI-PGD), fetal anomaly risk is high. Therefore, careful prenatal scanning is needed for these pregnancies.

Treatment of Virgin OHVIRA Syndrome with Haematometrocolpos by Complete Incision of Vaginal Septum without Hymenotomy.

Mullerian malformations result from defective fusion of the Mullerian ducts during development of the female reproductive system and have an incidence of 2-3%. The American Fertility Society classification of Mullerian anomalies is the most commonly utilized standardized classification. The least common form of these malformations is Herlyn-Werner-Wunderlich syndrome characterized by obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). This syndrome has been described with case reports since 1922. Early diagnosis and surgery that include drainage of fluid and resection of the vaginal septum is necessary for OHVIRA to prevent late complications (i.e. pyocolpos, chronic cryptomenorrhea). Here in we report a case of Herlyn-Werner-Wunderlich syndrome that hymen has been preserved during the operation of non-fenestrated transverse vaginal septum resection with hysteroscopy.

A comparison of misoprostol, controlled-release dinoprostone vaginal insert and oxytocin for cervical ripening.

OBJECTIVE: We compared the safety and effectiveness of oxytocin, dinoprostone and misoprostol for cervical priming. STUDY DESIGN: A total of 218 patients were enrolled to receive between one and three treatments according to physicians' options. The end points were: (1) vaginal delivery or Bishop score ≥ 8 at the end of 12 h, (2) vaginal delivery by 12 h or difference ≥ 4 between the initial and 12th hour Bishop scores. Statistical analyses were performed with ANOVA, Krustal Wallis, Scheffe, χ², Fisher, Advanced χ², and Kolmogorov-Smirnov tests. Tukey's HSD was used as a post hoc test. RESULTS: Misoprostol showed statistical significance for the rate of vaginal delivery <12 h, ≥ 8 Bishop score at the end of 12 h, and cervical change of ≥ 4 Bishop scores within 12 h (p = 0.013). CONCLUSIONS: Comparison between cases Bishop score <4 showed that misoprostol is more effective than dinoprostone and oxytocin. Considering Bishop score = 0 cases we calculated no statistical significance.