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.

Non-tubal ectopic pregnancy treatment experiences of a tertiary care center.

AIM: To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center. MATERIAL AND METHODS: A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated. RESULTS: In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96 mm vs. 17,34 ± 9,87 mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic inflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05). CONCLUSION: The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases.

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.

Peripartum Hysterectomy Outcomes: Our Eleven-Year Experience at a Tertiary Care Hospital.

Aim: To investigate the outcomes of peripartum hysterectomies (PHs) conducted to prevent maternal morbidity and mortality at a tertiary care hospital with 15,000 deliveries per year. Method: Patients who underwent PHs during delivery and/or within 24 h of delivery between the years 2011-2022 were retrospectively evaluated. Hysterectomies not performed in the peripartum period, cases that were managed by methods such as balloon tamponade, compression suture, or arterial ligation rather than hysterectomy, and hysterectomies performed before 20 weeks were excluded. Obstetric and demographic characteristics of the cases, as well as indications and outcomes of PH, were investigated. Results: Among the 130 patients who underwent PH, 4 (3.04%) patients delivered vaginally, 1 (0.7%) patient delivered vaginally after cesarean section, 12 (9.2%) patients delivered by primary cesarean section, and 113 (86.9%) patients delivered by secondary cesarean section. Placenta accreta spectrum disorder was the reason for PH in 54.6% (n = 71) of the cases while 16.1% (n = 21) underwent PH due to uterine atony. The PH rate was 0.75 per 1000 births, and the maternal mortality rate was 7.6 per 1000 hysterectomies in this study. Conclusion: Obstetricians in developed/ing countries support the active management of the third stage of labor mainly to mitigate the preventable risk factors of post-/peri-partum hemorrhage. The current study suggests that obstetricians need to focus on the placenta in order to reduce PH.

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.

The Effect of Disulfiram in the Prevention of Postoperative Adhesion Formation in an Experimental Rat Uterine Horn Model.

Postoperative adhesions can cause serious complications, including intestinal obstruction, chronic abdominopelvic pain, and infertility in women. Here we investigate the effects of disulfiram on the postoperative adhesion model. Female Wistar rats were used (n = 72). The animals were separated into six groups (12 rats per group): group 1 (control), group 2 (300 mg/kg disulfiram administered for 3 days preoperatively), group 3 (50 mg/kg disulfiram administered for 3 days preoperatively and 14 days postoperatively), group 4 (300 mg/kg disulfiram administered for 3 days preoperatively and 14 days postoperatively), group 5 (50 mg/kg disulfiram administered 14 days postoperatively only), and group 6 (300 mg/kg disulfiram administered 14 days postoperatively only). A histopathologic examination was performed. Immunohistochemical stainings for matrix metalloproteinase-2 and 9 (MMP-2, and MMP-9) and vascular endothelial growth factor (VEGF) were evaluated. The macroscopic adhesion scores were significantly lower in the disulfiram groups (groups 3, 4, and 6) compared to the control group (p < 0.05). Inflammation scores were lower in all groups receiving disulfiram, but only reached statistical significance in group 4 (p < 0.05). In the immunohistochemical evaluation of the groups, MMP-9 was significantly lower in group 5 than group 4 (p < 0.05). There was no significant difference between the groups for MMP-2 and VEGF. We found that disulfiram reduced postoperative adhesion formation. Disulfiram becomes more effective (by directly reducing inflammation) when initiated during the preoperative period at high doses.

The effect of the modes of delivery on the maternal and neonatal dynamic thiol-disulfide homeostasis.

Background: Thiols are organic compounds containing sulfhydryl groups which exert antioxidant effects via dynamic thiol-disulfide homeostasis. The shift towards disulfide indicates the presence of oxidative environment. The thiol-disulfide homeostasis has not been studied in different mode of delivery before. Aims: To investigate the effects of mode of parturition on the thiol-disulfide homeostasis in mothers and term infants. Study design: The participants were grouped according to the mode of their delivery: group vaginal delivery (VD, n = 40) and group cesarean section (C/S, n = 40). Three serum samples were collected: from mothers at the beginning of labor, from the cord blood (CB), and from the infants at the 24th hour after birth. The dynamic thiol-disulfide homeostasis in both groups were compared. Results: The levels of native-thiol and total-thiol in CB were significantly higher in VD group than those with C/S group. The levels of disulfide were higher in infants born by C/S compared with those born by VD. The disulfide-to-native thiol ratio, disulfide-to-total thiol ratio, and native thiol-to-total thiol ratio were similar between two groups. Conclusion: Our results showed that the dynamic thiol-disulfide homeostasis of the neonate was greatly influenced by the way of delivery and supported that vaginally delivered infants have less oxidative stress.