Risk factors for relaparotomy after cesarean delivery and related maternal near-miss event due to bleeding.

Aim: To define the risk factors for relaparotomy after cesarean delivery (RLACD) and related maternal near-miss event due to bleeding.Methods: In this retrospective descriptive case-control study, women who underwent RLACD (n = 46) only for bleeding between 2012 and 2017 were reviewed. Factors that could predict relaparotomy and related near-miss event were evaluated. Maternal characteristics, laboratory findings and surgical features were compared with a control group (n = 230) that included noncomplicated cesarean deliveries (CD). Logistic regression analysis was used to identify independent factors for relaparotomy.Results: RLACD for bleeding was required in 0.26% of patients and the incidence increased gradually over years (0.16% in 2013 versus 0.44% in 2017). Mean interval between CD and subsequent relaparotomy was 15.7 ± 3.2 hours. The sources of bleeding in descending order of frequency included; uterine fundus and placental bed (39.1%), cervix (21.7%), undetermined (17.3%), superior epigastric artery (13%), superficial epigastric artery (8.1%). Longer duration of CD (adjusted odd ratio (aOR) 1.82, 95% CI 1.02-2.53), increased number of prior CDs (aOR 2.51, 95% CI 1.09-5.78), preeclampsia (aOR 3.48, 95% CI 1.21-7.19) were found to be independent risk indicators for RLACD. Moreover, longer duration of interval between CD and relaparotomy (p = .005), longer relaparotomy duration (p = .012) and greater drop in hemoglobin level (p = .001) were found to be the predictors of maternal near-miss event.Conclusions: Patients with identified risk factors should be managed properly in order to prevent relaparotomy and near-miss event after CD. Also, urgent decision of surgical intervention might reduce the risk of maternal near-miss event.

Prenatal diagnosis of Seckel syndrome at 21 weeks' gestation and review of the literature.

BACKGROUND: The Seckel syndrome is an autosomal recessive inherited disorder that characterized severe pre- and post-natal growth restriction, microcephaly and a bird-like fetal head appearance. A few clinical reports revealed prenatal sonographic findings in the literature. CASE: A 29-year-old, Turkish, gravid 3, para 2, woman was referred to our center for further evaluation of a suspicion of microcephaly at 21 weeks' gestation. The couple was third degree consanguineous. Detailed 2- and 3-dimensional sonography scan revealed a bird-headed appearance, prominent eyes with hypotelorism, a severe microcephaly (bi-parietal diameter and head circumference were both < 1. Percentile for 21 weeks' gestation), a beaked nose, and increased nuchal fold thickness measurement (> 95th percentile), low-set and prominent ears. All sonographic findings suggested Seckel syndrome and the couple elected termination of pregnancy in the present case. SUMMARY: Seckel syndrome should be kept in mind in the differential diagnosis of severe microcephaly, accompanied by fetal growth restriction. 3D ultrasound is a useful adjuvant to routine 2D sonography for prenatal diagnosis of the syndrome and can delineate abnormal fetal head appearance (a bird-headed profile).

The Utility of Feticide Procedure to Shorten the Induction-to-Abortion Interval in Medical Abortion.

AIM: To evaluate the effect of intracardiac potassium chloride feticide procedure (FP) on the induction-to-abortion (I-to-A) interval for various indications in the termination of pregnancy. METHOD: Medically indicated abortions between 17 and 28 weeks' gestation were retrospectively evaluated and allocated into 2 groups: Cases with (group 1, n = 58) or without an FP (group 2, n = 60). I-to-A intervals were compared across the groups, considering different baseline parameters and fetal abnormality categories. RESULTS: There were no differences among the groups except in gestational age (GA; mean, 21.2 vs. 19.6 weeks, p = 0.01) in group 1. Overall, the I-to-A interval was shorter (900 ± 233 vs. 1,198 ± 375 min, p = 0.001) and prolonged medical abortion (I-to-A interval > 48 h) was less common (2% vs. 6%, p = 0.03) in group 1. The facilitating effect of FP persisted when indications were categorized as central nervous system, chromosomal, other structural abnormalities, and unclassified conditions. Logistic regression analyses demonstrated the following features to be associated with expulsion of fetus after 24-h: (1) advanced GA (> 24 week; aOR 6.9, 95% CI 3.24-14.72), (2) central nervous system abnormalities (aOR 5.3, 95% CI 2.6-11.4), (3) lack of feticide (aOR 3.67, 95% CI 2.24-10.72). CONCLUSION: FPs seem to shorten the I-to-A interval and decrease prolonged I-to-A interval rates. This facilitating effect remains unchanged for various medical indications.

The role of anti-Mullerian hormone in predicting the response to clomiphene citrate in unexplained infertility.

OBJECTIVE: To determine the role of anti-Mullerian hormone (AMH) levels in predicting the response to clomiphene citrate (CC) therapy for ovulation induction in women with unexplained infertility. MATERIALS AND METHODS: For this retrospective study, fifty consecutive patients who responded to CC were taken as Group 1, while fifty consecutive patients who failed to show adequate ovulatory response with CC were taken as Group 2. We compared the AMH levels of the two groups and receiver operating characteristic (ROC) curve was used to determine the threshold for AMH in predicting the ovulatory response to CC therapy. RESULTS: Mean age, body mass index, luteinizing hormone, prolactin, and thyroid-stimulating hormone values were similar in the two groups. AMH and antral follicle count (AFC) values were higher in Group 1 than in Group 2 (p = 0.001 and p = 0.001, respectively). There was a statistically significant negative correlation between FSH and AFC (r = -0.339, p = 0.001), while AFC and AMH displayed a statistically significant positive correlation (r = 0.713 and p = 0.001). AMH values and AFC were found to be predictors of the adequate ovulatory response to CC. The area under the ROC curve was 0.86 vs 0.80, respectively. At an AFC cutoff value of 14, the sensitivity and specificity for prediction of ovulation were 68% and 80%, respectively. CONCLUSION: The AMH and AFC cut-off values for the prediction of positive ovarian response to CC in patients with unexplained infertility were 2.78 ng/mL and 14, respectively. If further prospective and randomized studies confirm our results, these thresholds may be useful to predict successful ovulation induction and reduce the unresponsive cycles.

The impact of concurrent pelvic organ prolapse reconstructive surgery on midurethral sling procedure outcome.

OBJECTIVES: To evaluate the effect of concurrent pelvic organ prolapse (POP) reconstructive surgery on midurethral sling (MUS) procedure outcome. MATERIAL AND METHODS: The present retrospective study included 300 women with urodynamically diagnosed stress urinary incontinence that underwent MUS procedures with or without concurrent POP reconstructive surgery. Patients were divided into four groups according to the performed surgery; 1) transobturator tape (TOT), 2) TOT with POP surgery (anterior colporrhaphy, posterior colporrhaphy and vaginal hysterectomy), 3) tension free vaginal tape (TVT), 4) TVT with POP surgery. Outcomes of surgeries for each group were evaluated postoperatively at the end of the first and sixth month by performing a cough stress test and also using the Incontinence Impact Questionnaire-7 (IIQ-7) and Urogenital Distress Inventory (UDI-6) questionnaires. Presence of a negative cough stress test was defined as "Cure". Multivariate regression was used to identify the parameters for surgical failure. RESULTS: Forty-two, 70, 49 and 139 women underwent isolated TOT, concurrent TOT and POP, isolated TVT and concurrent TVT and POP surgery, respectively. Postoperative UDI-6 score and postoperative cure rate were significantly higher in the only TOT group as compared to the TOT + POP group. However, in multiple regression analysis, women's age, parity, body mass index, menopausal status, preoperative urodynamic parameters, MUS types and presence of any concomitant POP reconstructive surgery were found to have no significant effect on surgical outcome. CONCLUSIONS: Concurrent POP reconstructive surgery including anterior colporrhaphy, posterior colporrhaphy and vaginal hysterectomy have no affect MUS procedure outcomes.

Prenatal sonographic diagnosis of cephalopagus conjoined twins at 14 weeks of pregnancy.

Conjoined twins are extremely rare and are a type of monozygotic twins that occur due to an incomplete embryonic division on postconception day 13 to 15. Eight different types of conjoined twins have been described in the literature. Management of the condition depends on the site and extent of the union. We present a case of cephalopagus twins diagnosed at 14 weeks of gestation.

Comparison of bupivacaine and ropivacaine in combination with fentanyl used for walking epidural anesthesia in labor.

OBJECTIVE: Effective pain relief during labor is essential to reduce maternal and perinatal morbidity arising due to pain-induced maternal sympathetic activation, and to avoid unnecessary cesarean sections performed due to maternal anxiety. Walking epidural analgesia on labor reveals lower pain scores, leading to higher maternal satisfaction with better cardiovascular and pulmonary physiology. Despite the extensive use and relative safety of bupivacaine, newer drugs such as ropivacaine have been developed as alternative agents to decrease the risk for cardiac and central nervous system toxicity. MATERIALS AND METHODS: One hundred women who requested epidural analgesia in active labor were randomly allocated into two groups; one group received 20 mL of ropivacaine 0.125% with fentanyl 50 µg and the other received 20 mL of bupivacaine 0.125% with fentanyl 50 µg. The efficacy of analgesia, adverse effects, and obstetric and neonatal outcomes of both groups were compared. RESULTS: There were no differences between the two study groups in the measured obstetric and neonatal outcomes. The onset time, duration of analgesia, and sensory levels were similar between the groups. Visual analog pain scale scores did not differ between the groups before analgesia or at any of the subsequent evaluation periods. CONCLUSION: Both ropivacaine and bupivacaine provide equivalent labor analgesia with high maternal satisfaction and tolerable adverse effects in the clinically used dose range. No adverse obstetric or neonatal outcomes were observed in either group. Therefore, either drug is a reasonable choice for labor analgesia and can be used without jeopardizing the safety of the mother and fetus.

The significance of reverse flow in ductus venosus between sixteen and twenty weeks' gestation.

OBJECTIVE: To evaluate the correlation between reversed a-wave in ductus venosus at 16-20 weeks' gestation and trisomy 21 and adverse perinatal outcomes. MATERIALS AND METHODS: Our study included 174 pregnant women who were under follow-up at a tertiary center between May and September 2010. Ductus venosus Doppler (DVD) measurements were obtained throughout the 6-month period from women who underwent amniocentesis procedures due to increased risk for trisomy 21 in terms of first or second trimester screening test results. These women were followed up for enrollment of subsequent data about perinatal outcomes. RESULTS: In 13 of 174 cases, Doppler studies indicated a reversed a-wave in the ductus venosus. Of these fetuses, 3 were diagnosed as having trisomy 21 after amniocentesis, which related to 60% (3 of 5 fetuses) of all fetuses with trisomy 21. The pregnant women with reversed a-wave in DVD also had an increased rate of preeclampsia (15%) and gestational diabetes mellitus (GDM) (23%) in late pregnancy. CONCLUSION: Reversed a-wave in ductus venosus between 16-20 weeks' gestation is associated with increased risk of trisomy 21, preeclampsia, and GDM. If further prospective studies confirm its utility, DVD interrogation for trisomy 21 may be extended until 20 weeks' gestation.

Prenatal diagnosis of inverted duplication deletion 8p syndrome mimicking trisomy 18.

Inverted duplication deletion of 8p (invdupdel[8p]) is a well-described and uncommon chromosomal rearrangement. The majority of the reported cases have revealed no life-threatening malformations. Although the invdupdel[8p] syndrome in children with central nervous system abnormalities has been reported before, we present the first prenatal microarray diagnosis of invdupdel[8p] syndrome mimicking trisomy 18 due to similar sonographic features. Contrary to reported cases with invdupdel[8p] syndrome, the present case had severe polyvalvular dysplasia and the infant deceased at day 12 of life. In this case, we also emphasize the diagnostic power of microarray analysis in detecting the underlying genetic causes for fetuses with multiple congenital anomalies. © 2017 Wiley Periodicals, Inc.

Maternal serum ferritin as a clinical tool at 34-36 weeks' gestation for distinguishing subgroups of fetal growth restriction.

OBJECTIVE: To compare maternal ferritin levels across pregnancies with fetal growth restriction including SGA and IUGR compared to appropriate for gestational age (AGA). METHODS: Three groups were enrolled: AGA, SGA (birth weight below 10th percentile for gestational age with no placental insufficiency findings), and IUGR (birth weight below 5th percentile for gestational age accompanied by abnormal umbilical artery Doppler waveforms and/or oligohydramnios). Maternal serum ferritin samples were obtained at gestational weeks 34 through 36, and delivery occurred at or beyond 36 weeks. RESULTS: A total of 126 pregnancies with AGA (36%), SGA (40%), and IUGR (24%) were enrolled. The mean maternal serum ferritin level was higher in the IUGR group than in the AGA group (59 µg/l versus 32.5 µg/l, p < 0.001). A maternal serum ferritin cutoff of 48 µg/l was found to be optimal for distinguishing between IUGR and AGA with a sensitivity of 67.7%, specificity of 92%, PPV of 84%, NPV of 82%, diagnostic accuracy of 82.7%, LR + of 8 and LR- of 0.3, respectively. CONCLUSION: Maternal serum ferritin levels differ in pregnancies with IUGR. The role of maternal serum ferritin measurements as a clinical tool for distinguishing different forms of fetal growth restriction warrants further investigation.

Can we consider cesarean myomectomy as a safe procedure without long-term outcome?

AIM: To investigate short- and long-term outcomes in women undergoing cesarean myomectomy (CM). METHODS: This was a retrospective study that explored short-term outcomes of women, who underwent cesarean operations with or without myomectomies (CM controls) in a single tertiary center throughout a 6-year-period. For long-term outcomes, the mean duration of follow-up was 6.3 ± 1.0 years. RESULTS: There were no differences among the CM (n= 91) and control groups (n = 60) considering mean change in hemoglobin and hematocrit levels, hemorrhage, as well as requirement for blood transfusions with a slightly increased operative time. Multiple myomas, and cervical and cornual localization were associated with an increased drop of hemoglobin and hematocrit (p < 0.05). Subsequent pregnancy and recurrence rates were 35% (32/91) and 5.5% (5/91), respectively. Preterm delivery (n = 1, 3.1%), uterine dehiscence (n = 1, 3.1%), placenta previa (n = 1, 3.1%) and mild-to-severe post-CM adhesions (n = 8, 25%) were observed in subsequent pregnancies. Recurrence was identified in five of the nonpregnant (5.5%) women, and three of these (4.1%) underwent an additional major surgery. There was no recurrence in subsequent pregnancies. CONCLUSION: The recurrence of myoma was relatively low following CM. Subsequent pregnancy is protective for recurrence of myoma without increased adhesion formation and obstetric complications.

Maternal and perinatal outcomes in pregnancies with multiple sclerosis: a case-control study.

OBJECTIVE: To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center. METHODS: We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ2 tests. Logistic regression models were constructed to determine independent effects. RESULTS: Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models. CONCLUSION: MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

Reliability of posterior-left atrium space index measurements during 20-24 weeks of gestation in structurally normal fetuses.

OBJECTIVE: We aimed to evaluate the correlation between clinical parameters and the post-left atrium (LA) space index, which is a candidate screening marker for total anomalous pulmonary venous connection (TAPVC). We also calculated the inter- and intra-observer variabilities of measurements for this parameter. METHODS: The LA-descending aorta distance/descending aorta diameter ratios (post-LA space index) were obtained from 165 fetuses between 20 and 24 weeks of gestation. Regression analyses were utilized to evaluate the correlations across clinical parameters and the post-LA space index. Intraclass correlations coefficients were calculated for the intra- and inter-observer agreements of three examiners with different sonographic experience. RESULTS: The mean (±SD) maternal and gestational age (GA) was 28.6±4.9 years and 21.7±0.9 weeks of gestation, respectively. In multivariate analyses, there was no correlation between post-LA space index and maternal age, fetal gender, or GA at cardiac scan. There were moderate to strong correlations across the measurements by different examiners, indicating good inter- and intra-observer agreements. CONCLUSION: The post-LA space index during 20-24 weeks of gestation is a simple and reliable marker that is not affected by GA. However, its potential as a screening tool for TAPVC warrants further clinical investigation.

Conventional 22- and 20-gauge needle for second trimester amniocentesis: A comparison of short term outcomes.

OBJECTIVE: To compare the short-term outcomes of two different-sized needles for genetic amniocentesis. MATERIALS AND METHODS: A total of 271 amniocentesis were retrospectively evaluated in 2 groups concerning the size of the needles used during the procedure: Conventional 20-gauge (G) (n=164) and 22G (n=107). Periprocedural complications and cost-effectiveness were compared across the groups. RESULTS: There were no differences between groups concerning complications within 15 days after the procedure (fetal loss, 0.6% versus 0.9%, and amniotic fluid leak 1.2% versus 1.8%, p=0.99 for each). The 22G needle was significantly more cost efficient (p<0.0001). CONCLUSION: The 22 G spinal needle is convenient for second trimester amniocentesis with similar complication rate and has a favorable cost profile.

A comparison of the effects of the most commonly used tocolytic agents on maternal and fetal blood flow.

OBJECTIVE: To investigate the effects of two tocolytics, nifedipine and magnesium sulfate, on Doppler indices in maternal and fetal vessels. MATERIALS AND METHODS: We recruited 100 pregnant women with preterm birth between 24-36 gestational weeks who were admitted to our tertiary center over a two-year period. Patients were allocated to nifedipine (n=49) and magnesium sulfate (n=51) groups and Doppler indices of umbilical, middle cerebral, uterine arteries, and ductus venosus were measured before and after tocolysis. RESULTS: There were no differences between the groups in terms of maternal age, gestational week, body mass indexes, cervical dilation, effacement at admission, birth weights and latency periods until birth. Nifedipine decreased resistance indexes in uterine arteries but magnesium sulfate increased resistance especially in the right uterine artery. Nifedipine significantly decreased systole to diastole and resistance index in the umbilical artery, magnesium sulfate increased systole to diastole and resistance index but this was not statistically significant. Nifedipine acted variably on resistance index and pulsatility index in the ductus venosus; however, magnesium sulfate increased resistance. Nifedipine decreased pulsatility index in the middle cerebral artery, contrary to magnesium sulfate with which it increased. CONCLUSION: Nifedipine had favorable effects on maternal and fetal vessel indexes but magnesium sulfate increased resistance. Despite the proposed neuroprotective benefits of magnesium sulfate, nifedipine seems to be a better and safer tocolytic agent than magnesium sulfate due to its positive beneficial effects on maternal and fetal vessels.

The evaluation of risk factors for failed response to conservative treatment in tubo-ovarian abscesses.

OBJECTIVE: The aim of our study is to assess the risk factors for medical treatment failure and to predict the patients who will require the surgical therapy as well as to predict the factors affecting treatment success. MATERIAL AND METHODS: This was a cross-sectional study including 76 women with tubo-ovarian abscesses (TOA) who were either conservatively or surgically treated and were admitted to two gynecology units over a 4-year period. The demographic characteristics of the patients, gynecologic and obstetric histories, size and localization of abscesses were recorded. Gentamicin plus clindamycin treatment protocol was implemented for all patients. Ampicillin treatment was added in three patients with the positive culture of Actinomyces. Response to treatment was evaluated after 48-72 h. Patients who fail to respond to medical treatment required surgery or percutaneous drainage. We compared clinical and laboratory factors between the groups. RESULTS: In surgery group, patients were significantly older than the others (44.9±5.4 versus 39.1±7.6 years). Fifty-six patients (74%) responded to antibiotics and 20 of the patients required surgical intervention. Patients treated with antibiotics were hospitalized for an average of 6.32±2.8 days versus 12.75±5.6 days for those who required surgery (p=0.021). Patients who were surgically treated had a mean size of TOA of 67.9±11.2 mm versus 53.6±9.4 mm for those treated with antibiotics alone (p=0.036). There were no significant differences between groups in laboratory parameters, except for initial white blood cell (WBC) counts. The complications of surgery included in descending order of frequency blood transfusions, surgical wound infections, bowel injury, and bladder injury. CONCLUSION: An increased size of pelvic mass, higher initial WBC counts, advanced age, and smoking were all associated with failed response to conservative treatment. It is important to identify the risk factors to distinguish patients who will respond to antibiotic therapy and those who will need a surgical treatment. Thus, the required early intervention can result in a reduction in the morbidity associated with TOA.

Laparoscopic systemic devascularization of uterine cornu for cornual resection in interstitial pregnancy.

Cornual pregnancies carry a greater maternal mortality risk than ampullary ectopic pregnancies and they may cause significant hemorrhage. A woman aged 36 years with a six-week history of amenorrhea, slight vaginal bleeding, and low abdominal pain of three days duration presented to our clinic. A diagnosis of right cornual ectopic pregnancy was made using ultrasonographic findings. Laparoscopic exploration confirmed the diagnosis. We occluded the uterine artery at its origin and also transected vessels within the mesosalpinx and uteroovarian ligament to successfully accomplish avascularization of a cornual pregnancy. Occlusion of the uterine arteries is reported to be a safe and blood-sparing technique. Severe hemorragia may occur during the operation; therefore, techniques to minimize blood loss are reported. In our case, occlusion of the uterine artery and transection of the mesosalpinx and uteroovarian vessels provided a bloodless operation and there was no need to bilaterally occlude vessels.

Utero-cutaneous Fistula after Multiple Abdominal Myomectomies: A Case Report.

BACKGROUND: Utero-cutaneous fistula (UCF) is an extremely rare entity and only a few case reports have been published. Most UCFs develop secondary to post-partum or postoperative complications. CASE REPORT: A 42 year-old woman began to complain from bleeding and malodorous discharge through her abdominal incision scar. The fistula tract with a thickness of 8 mm was observed between the uterus and wound using magnetic resonance imaging (MRI). The risks and benefits of conservative treatment have been discussed; the patient demanded definitive treatment, so hysterectomy and excision of the fistulous tract was performed. Histopathology of the fistulous tract showed endometrial epithelization of the tract lined by granulation. CONCLUSION: There are many causes of such an extremely rare entity. Patients should be counseled for medical or surgical treatment considering their age, accompanied uterine pathologies such as fibroids and fertility expectations.