The effect of inducible nitric oxide synthase on postoperative adhesion formation in rats.

OBJECTIVE: To evaluate the effect of iNOS on adhesion formation and to assess whether inhibition of iNOS expression affected adhesion formation according to adhesion maturation days. STUDY DESIGN: Forty Wistar Albino rats were subjected to standardized lesion by cecal abrasion and parietal peritoneal defect and were randomly divided into four groups. Group I (control) received no treatment; groups II-IV received N-acetyl-cystein (NAC) 15 mg/100 g per day intramuscularly on days 4-14, 0-14 and 0-3, respectively, after surgery. On the postoperative 14th day adhesion score, tissue iNOS expression, inflammatory cell reaction (ICR) and tissue fibrosis score were determined. RESULTS: Inflammation score of groups I and II was lower than that of groups III and IV (P < 0.05). Adhesion scores and tissue fibrosis of group II were significantly lower than that of the other groups (P < 0.001). CONCLUSION: iNOS inhibition during the first 3 days postoperatively caused a delay in the resolution of inflammatory cell reaction. On the other hand, when inhibited after the first 3 days, adhesion formation and fibrosis were reduced both clinically and histopathologically.

Ovarian function and vascular resistance after tubal sterilization.

OBJECTIVE: To investigate the effect of tubal sterilization (laparoscopic bipolar coagulation) on serum baseline follicle-stimulating hormone (FSH) and estradiol levels, ovarian volume, antral follicle counts and ovarian artery blood flow rate and to evaluate the correlation of these parameters. STUDY DESIGN: Nineteen women who underwent tubal sterilization with laparoscopic bipolar coagulation were enrolled in the study. Ovarian volume, antral follicle counts, serum hormone levels and ovarian artery resistivity index values were measured before and 1 year after the sterilization procedure on the third day of the menstrual cycle. RESULTS: Serum hormone levels, mean ovarian volume (MOV) and mean follicle counts (MFC), were not statistically significant before and 1 year after the operation (P > .05). The difference in ovarian artery resistivity index values was not statistically significant before and 1 year after the operation (P > .05). A significant correlation was observed between FSH, MOV and MFC before and after the operation (P < .05). No correlation was observed between MOV or MFC and resistivity index. CONCLUSION: Ovarian function and vascular resistance do not seem to be affected by laparoscopic bipolar tubal coagulation.

The effect of circulating androgens on bone mineral density in postmenopausal women.

BACKGROUND: Osteoporosis is a common problem in postmenopausal period. Recent studies have suggested that endogenous and exogenous androgens may influence the bone mineral density in women. There is limited data about the effect of circulating androgens on bone density in postmenopausal women. AIM: The aim of this study was to evaluate the effect of circulating androgens of ovarian and adrenal origin on bone mineral density in postmenopausal women. MATERIALS AND METHODS: This cross-sectional study included 178 postmenopausal women, who had never been treated with hormonal therapy or calciotropic agents. Serum free testosterone, dehydroepiandrosterone sulfate and androstenedione levels and their relationship with bone mass (dual X-ray absorptiometry) were evaluated. RESULTS: Serum free testosterone and DHEAS levels were correlated positively with bone mineral density at lumbar spine and femoral neck (P < 0.001). However, stepwise linear regression analyses revealed a differential effect of androgens on bone density. Serum free testosterone was among the independent predictor of bone density at lumbar spine (trabecular bone), whereas serum DHEAS level was of bone density at femoral neck (cortical bone). CONCLUSION: This study suggests that endogenous androgens are influential on bone density in postmenopausal women. However, regression analyses revealed a differential effect of androgens on different bone types.

Treatment of a cervical viable pregnancy with a single intraamniotic methotrexate injection: a case report.

INTRODUCTION: Cervical pregnancy is a rare condition, constituting <1% of all ectopic pregnancies. CASE REPORT: We report here, the successful management of a viable 7 weeks gestation cervical pregnancy. Feticide with 2 ml of potassium chloride 15% was performed under the guidance of transvaginal ultrasonography. Then 70 mg methotrexate (50 mg/m(2)) was injected through this spinal needle in to the amniotic cavity. Also serial changes in the color Doppler imaging after the methotrexate injection were emphasized.

Comparison of transperineal and transvaginal sonography in predicting preterm delivery.

PURPOSE: A major advantage of transperineal sonography (TPUS) is its ability to evaluate the cervix without causing any distortion. This study was performed to compare transvaginal sonography (TVUS) and TPUS at 24 weeks of gestation in predicting preterm delivery in low-risk pregnancy. METHODS: Three hundred fifty-seven pregnant women underwent TVUS and TPUS at 24 weeks of gestation. The relationship between cervical length and preterm delivery was assessed. Accuracy values of TVUS and TPUS at 24 weeks of gestation were compared in predicting preterm delivery. RESULTS: Preterm delivery (before 36 weeks of gestation) occurred in 22 pregnancies (6.2%). Mean cervical lengths measured by TVUS and TPUS were significantly different in preterm and term delivery groups (P < 0.05). Areas under the curves were 0.801 and 0.857 for the transvaginal and transperineal measurements, respectively. The coefficient of correlation between the transvaginal and transperineal cervical length measurements was 0.83. TPUS had a sensitivity of 77% in predicting preterm delivery, with a false-positive rate of 17% and a relative risk of 4.5 at the 32.5-mm cutoff value. CONCLUSIONS: When the cervix is well visualized, TPUS can predict preterm delivery as accurately as TVUS.

Early second-trimester individualized estimation of trisomy 18 risk by ultrasound.

OBJECTIVE: To report two second-trimester ultrasound algorithms for trisomy 18 prediction. METHODS: Femur length, gross anomaly, choroid plexus cysts, two-vessel cord, and maternal age were documented in pregnancies undergoing genetic amniocentesis. Stepwise logistic regression was used to identify 1) the significant markers for predicting trisomy 18 when gross anomaly was not considered (algorithm 1) and 2) when gross anomaly was also considered (algorithm 2). Patient-specific risk was calculated based on the significant ultrasound markers plus maternal age. The diagnostic accuracy of each algorithm was determined. RESULTS: There were 1167 normal and 47 trisomy 18 cases. The mean gestational ages were 16.5 weeks (standard deviation [SD] 1.5) and 17.9 weeks (SD 1.6), respectively. Algorithm 1 consisted of maternal age, choroid plexus cyst, femur length, and two-vessel cord. The sensitivity and false positive rates were 61.7% and 1.5%, respectively, with an area under the receiver operating characteristics curve of 0.880 (P <.001). Algorithm 2 (age, femur length, gross anomaly, and choroid plexus cyst) had a sensitivity of 72.3% and false positive rate of 0.9% with an area under the curve of 0.956 (P <.001). Comparable detection rates were achieved in early gestation at up to and including 17.5 weeks (72.4% and 82.8%, algorithms 1 and 2, respectively, at a 4.0% false positive rate). CONCLUSION: The ultrasound markers were sensitive for trisomy 18 detection in the early second trimester.

Diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps.

AIMS: To evaluate the diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps. METHODS: Thirty-two women whose preliminary transvaginal ultrasound suggested endometrial abnormality underwent sonohysterography. The findings were then compared with histopathological results. RESULTS: The sonohysterographic diagnosis was fibroid in seven patients, endometrial polyp in 23 patients and simple hyperplasia in two patients. Histopathological findings confirmed our diagnosis in all except three patients with endometrial polyps, who had normal secretory endometrium. Sonohysterography was found to have a sensitivity of 100%, a positive predictive value of 90% and diagnostic accuracy of 90.6%. CONCLUSION: Sonohysterography is a useful, minimally invasive and accurate technique to evaluate the pathologies involving endometrium and uterine cavity.

Early genetic sonogram for Down syndrome detection.

OBJECTIVE: The purpose of this study was to determine the Down syndrome sensitivity of early genetic sonography (14-<16 weeks of gestation) and to compare its diagnostic accuracy with that later in the mid trimester (16-24 weeks of gestation). STUDY DESIGN: Nuchal thickness, humerus and femur lengths, hyperechoic bowel, hypoplastic fifth digit (clinodactyly), and any gross anatomic defects were measured or ascertained in singleton pregnancies that were undergoing genetic amniocentesis. Multiple stepwise logistic regression analysis was used to determine the significant sonographic markers for Down syndrome detection in each group. Multivariate gaussian algorithms that included maternal age were used to estimate patient-specific Down syndrome risk. Sensitivity and false- positive rates, receiver-operating characteristic curves, and area under the curves were calculated and compared for both groups. RESULTS: There were 1,727 pregnancies with 22 Down syndrome fetuses (1.27%) in the early group versus 3,914 pregnancies with 86 Down syndrome fetuses (2.2%) in the later group. The mean +/- SD ages were 15.5 +/- 0.4 weeks versus 17.6 +/- 1.4 weeks, respectively. Early genetic sonography (14-<16 weeks) had a 100% detection rate, with a 21.2% false-positive rate. The early versus later genetic sonography had an 81.8% versus 61.6% detection rate, respectively, at a fixed 4.8% false-positive rate. Early sonography had significantly higher diagnostic accuracy (area under the curve, 0.962 vs 0.871, respectively; P =.005). In fetuses at 14 to 15 weeks, the genetic sonography was also highly accurate, with 100% detection with a 21.9% false-positive rate. CONCLUSION: Early genetic sonography is highly sensitive and statistically superior to later ultrasonography for Down syndrome detection. Early midtrimester sonography achieved a diagnostic accuracy similar to that currently reported for first-trimester nuchal translucency.

Midtrimester nuchal thickness and the prediction of postnatal congenital heart defect.

OBJECTIVE: The study was performed to determine the sensitivity of nuchal thickness measurements for the detection of congenital heart defects (CHD) and to develop an algorithm for estimating patient-specific risk of CHD. STUDY DESIGN: Nuchal thickness measurements (expressed as multiples of the median) were obtained in 3,003 midtrimester fetuses in which postnatal evaluation of the heart was available. The sensitivity and false-positive rate of nuchal thickness threshold values for detecting CHD were used to calculate the area under the receiver operating characteristics curve. Stepwise logistic regression analysis was used to determine the significant predictors of heart defect among nuchal thickness and epidemiologic risk factors. Individual risk of CHD was calculated on the basis of background population risk of major CHD (estimated at 4.4 of 1,000) and the product of the likelihood ratios of the significant risk factors from the logistic regression. RESULTS: There were 95 cases of confirmed CHD. Nuchal thickness was statistically significant for the prediction of CHD with an area under the curve = 0.58, P =.01. Nuchal thickness and prior child with CHD were the only significant predictors among the multiple risk factors for this disorder. Patient-specific risk estimates for CHD based on these two "markers" were calculated. It was accurate and improved the prediction of CHD, area under the curve = 0.63, P <.001, compared with nuchal thickness alone. CONCLUSION: Midtrimester nuchal thickness measurement significantly detected postnatally confirmed CHD in chromosomally normal fetuses. We report for the first time a method for estimating individual patient risk of CHD.

Accurate prediction of fetal hemoglobin by Doppler ultrasonography.

OBJECTIVE: To assess the feasibility of using the middle cerebral artery peak systolic velocity (MCA-PSV) to predict the actual value of fetal hemoglobin in fetuses undergoing a first cordocentesis for detection of anemia caused by maternal red cell alloimmunization. METHODS: Doppler velocimetry of the MCA-PSV was performed in 18 fetuses before an initial cordocentesis. Hemoglobin and MCA-PSV values were expressed as multiples of the median to adjust for the changes that both parameters demonstrate with gestational age. In each fetus we determined: 1) the expected (using a cubic mathematical function describing the correlation between fetal hemoglobin and MCA-PSV) and the observed (determined at the time of the cordocentesis) hemoglobin value; and 2) the percentage differences between the expected and the observed hemoglobin values. RESULTS: Gestational age at the time of the Doppler study ranged from 19 to 31 weeks. On 15 occasions, the fetuses demonstrated anemia. A quadratic relationship was found between the hemoglobin multiples of the median and the percentage differences between the expected and the observed hemoglobin values. As the values of hemoglobin decreased, the percentage difference between expected and observed values significantly decreased (R(2) = 0.48, P <.05). The cubic model estimated fetal hemoglobin well in severely anemic fetuses and less well when the fetus was not anemic. CONCLUSION: Doppler measurement of the MCA-PSV appears to be a valuable tool for estimating hemoglobin concentration in fetuses at risk for anemia. The correlation between hemoglobin and MCA-PSV becomes more accurate as the severity of anemia increases.

The comprehensive midtrimester test: high-sensitivity Down syndrome test.

OBJECTIVE: The purpose of this study was to develop a highly sensitive algorithm for midtrimester Down syndrome detection. STUDY DESIGN: Urine (hyperglycosylated human chorionic gonadotropin, beta-core fragment of human chorionic gonadotropin), serum (alpha-fetoprotein, human chorionic gonadotropin and unconjugated estriol [uE(3)]), and ultrasound biometry (nuchal thickness, humerus length, the presence of gross ultrasonographic anomalies), and maternal age were measured at genetic amniocentesis. Stepwise logistic regression analysis was used to identify the most significant markers. A multivariate Gaussian algorithm plus age was used to derive patient-specific Down syndrome risk. Sensitivity and false-positive rates at different risk thresholds and the area under the receiver-operating characteristic curve were determined. A probability value of <.05 was significant. RESULTS: There were 568 study cases with 17 Down syndrome cases (3.0%). The mean (+/-SD) maternal and gestational ages for the study group were 36.9 (+/-3.5) years and 16.2 (+/-1.4) weeks, respectively. The significant markers were nuchal thickness (P =.0001), hyperglycosylated human chorionic gonadotropin(P <.001), and beta-core fragment (P <.002). Neither maternal age nor gross sonographic anomaly contributed significantly to Down syndrome detection. The comprehensive midtrimester test was extremely efficient for Down syndrome detection in advanced maternal age only cases with a sensitivity of 92.3% at a 0.8% false-positive rate. In women <35 years old, all the Down syndrome cases were detected at 2.2% false positive rate. For the overall population, the sensitivity was 93.7% at 5% false-positive rate. CONCLUSION: In a preliminary study, the comprehensive midtrimester test appeared highly sensitive in different age groups. Gross anomaly detection was not required for high performance, which makes the comprehensive midtrimester test potentially suitable for low-risk screening and as an alternative to amniocentesis in women who wish to avoid the procedure. This was a small study; thus, the clinical value of this test can only be established in large trials.

Does menstrual flow exclude hematometra? A rare case of uterine anomaly presenting with anorectal malformation.

Hematometra, which is defined as accumulation of menstrual secretions in the uterine cavity, may not be diagnosed until the maturating adolescent fails to menstruate. Clinically, a lower abdominal mass and periodic abdominal pain may develop in these children after puberty. Here, a 13-year-old girl with menstrual flow who presented with symptoms of genital outflow tract obstruction is described.