Abdullah Tuten

The Incidence of Placental Abnormalities, Maternal and Cord Plasma Malondialdehyde and Vascular Endothelial Growth Factor Levels in Women with Gestational Diabetes Mellitus and Nondiabetic Controls

Background/Aims: To evaluate the incidence of placental abnormalities, cord plasma erythropoietin (EPO) levels and nucleated red blood cell (NRBC) counts, maternal and cord plasma malondialdehyde (MDA) and vascular endothelial growth factor (VEGF) levels in women with gestational diabetes mellitus (GDM) and nondiabetic controls. Methods: Twenty-two women with GDM, diagnosed according to the current criteria of the American Diabetes Association, were compared with 22 controls. Maternal and cord blood and placental samples were obtained from all pregnant women. Cord plasma EPO levels and NRBC counts, maternal and cord plasma MDA and VEGF levels were determined. Placental tissues were examined histologically. Results: Maternal and cord plasma levels of MDA and cord plasma EPO levels and NRBC counts were significantly higher in GDM pregnancies (p < 0.01). The presence of villous immaturity, chorangiosis and ischemia were significantly increased in the placentas of women with GDM (p < 0.05). The maternal and cord plasma levels of MDA increased (p = 0.007 and p = 0.001, respectively), whereas VEGF decreased (p = 0.046 and p = 0.001, respectively) with the presence of villous immaturity. Conclusion: The complex process of villous development and maturity might be influenced by the maternal and fetal oxidative and angiogenetic milieu. The placenta that shows abnormalities in angiogenesis and maturation may lead to fetal hypoxia and compromise.

Serum anti-mullerian hormone levels in the main phenotypes of polycystic ovary syndrome

OBJECTIVE To characterize the difference in circulating anti-Müllerian hormone (AMH) levels between the main polycystic ovary syndrome (PCOS) phenotypic groups and evaluate the role of AMH in predicting the severity of PCOS. STUDY DESIGN Cross-sectional, retrospective study. A total of 251 women were divided into four groups based on the main features of PCOS, as follows: Group 1 (polycystic ovarian morphology [PCOM]+/oligo-anovulation [OA]+/hyperandrogenism [HA]+), Group 2 (PCOM+/OA+/HA-), Group 3 (PCOM+/OA-/HA+), and Group 4 (PCOM-/OA+/HA+). AMH and other hormone levels were measured in serum. The main outcome was serum AMH concentrations in the main phenotypes of PCOS. RESULT(S) The mean serum AMH levels were 9.50±6.1 ng/mL in Group 1; 8.02±6.2 ng/mL in Group 2; 6.12±3.6 ng/mL in Group 3; and 3.06±2.4 ng/mL in Group 4. Circulating AMH levels in Group 1 (PCOM+/OA+/HA+) were three times higher than those in Group 4 (PCOM-/OA+/HA+). CONCLUSIONS The highest AMH levels were found in cases where all three main diagnostic criteria existed. AMH levels correlate best with PCOM. In addition, oligo-anovulation contributes to increased AMH levels. Hyperandrogenism criteria were found to have less influence on AMH levels. AMH levels seem to have a diagnostic role in determining the severity of PCOS.

Maternal serum and fetal cord blood irisin levels in gestational diabetes mellitus

AIM To investigate the relationship between maternal and cord blood irisin in gestational diabetes mellitus (GDM). METHODS Twenty women with GDM and 20 pregnant women with uncomplicated pregnancies were recruited for this case-control study. Maternal serum irisin and cord blood irisin levels were measured by enzyme-linked immunosorbent assay kit at the time of birth. The association of maternal serum and cord blood irisin levels with metabolic parameters was analyzed. RESULTS Women with GDM had significantly lower mean serum irisin levels compared to control group (258.3±127.9 vs. 393±178.9ng/ml, p<0.05). Mean cord blood irisin levels for GDM and control groups were not significantly different (357.2±248.0 vs. 333.2±173.4ng/ml, p>0.05). No significant differences were found in terms of maternal age, gestational week at birth, BMI at birth, birth weight, neonatal height, systolic and diastolic blood pressure between the groups as well (p>0.05). Serum irisin level was negatively correlated with BMI at birth and HOMA-IR (r=-0.401, p=0.010; r=-0.395, p=0.012, respectively). No correlations between irisin levels and others parameters were found in both groups. CONCLUSIONS Maternal serum irisin levels of patients with GDM are significantly lower compared with non-GDM controls. However, no significant difference was found between cord blood irisin levels of patients with GDM and healthy pregnant women.

Balloon tamponade for the management of postpartum uterine hemorrhage

Abstract Objective: To evaluate the use of the Bakri balloon in postpartum hemorrhage (PPH) resistant to medical treatment. Methods: The Bakri balloon was applied to 45 women with PPH after failure of initial management. Bilateral internal iliac artery ligation (BIIAL) and hysterectomy were performed if necessary. Results: The Bakri balloon was applied in 45 women; an additional BIIAL was required in nine women. The mean inflation volume of the Bakri balloon was 571±264 mL (range: 240–1300 mL). Hemostasis was achieved in 34 (75.5%) women with the Bakri balloon alone, and in six women with an additional BIIAL. The Bakri balloon was effective with additional procedures overall in 40 of 45 (88.8%) women. In 34 women with uterine atony, the Bakri balloon was successful alone in 27 (79.4%) and with an additional BIIAL in 30 (88.2%) women. An inflation volume of >500 mL was necessary in 18 women with uterine atony. Conclusion: The Bakri balloon may be performed as a first line of treatment for PPH resistant to uterotonic agents, and can be used not only in tertiary centers but also in limited-resource centers. The inflation volume of the Bakri balloon should be adjusted according to the type of PPH; a volume exceeding 500 mL may be necessary in uterine atony.

Pregnancy outcomes and prognostic factors in patients with intrahepatic cholestasis of pregnancy

Abstract The aim of this study was to describe maternal and fetal characteristics associated with intrahepatic cholestasis of pregnancy (ICP) and to determine clinical and biochemical predictors of fetal complications. A total of 89 singleton pregnancies with ICP were analysed, retrospectively. All data concerning laboratory results, symptom onset time, treatment response, delivery time and infant information were recorded in the study protocol. The mean gestational age at diagnosis was 32.6 ± 3.4 weeks; mean time of delivery was 36.8 ± 1.9 weeks. Binary logistic regression revealed that gestational age at diagnosis was predictive of preterm delivery (OR = 2.3, 95% CI: 1.5–3.3, p = 0.001). The incidence of respiratory distress syndrome (RDS), fetal growth restriction, fetal distress and preterm delivery were significantly higher in patients who were diagnosed before 30 weeks than after 34 weeks’ gestation (p < 0.01). Gestational age at diagnosis is an important independent factor predicting adverse perinatal outcomes in patients with ICP.

Evaluation of ovarian reserve in Hashimoto's thyroiditis

Abstract Human ovary is commonly the target of an autoimmune attack in cases of organ- or non-organ-specific autoimmune disorders. Hashimoto’s thyroiditis (HT) is likely to be associated with ovarian dysfunction and diminished ovarian reserve. In this study, we aimed to evaluate the possible negative association between this significantly prevalent autoimmune disease and the ovarian reserve. Thirty-two premenopausal women with primary hypothyroidism, who under replacement therapy with thyroxine were recruited. Forty-nine healthy female subjects who had normal anti-thyroid antibody levels and were comparable with the HT group in terms of age and BMI values, comprised the control group. There was no statistically significant difference between the study and the control patients in terms of antral follicle count. Serum anti-Müllerian hormone (AMH) levels were significantly higher in woman with HT compared to the control group. The results of this study found no impairment in ovarian reserve parameters of patients with HT. Interestingly, the results revealed a significant increase in serum AMH levels of the patients with HT compared to controls. Hashimotos thyroiditis may share a common etiologic linkage with polycystic ovary syndrome; therefore, leading to elevated serum AMH levels, which we are currently unable to define elaborately. Chinese abstract 人类卵巢经常成为器官特异性或非器官特异性自身免疫性疾病的靶器官。桥本甲状腺炎(HT)或与卵巢功能不全和卵巢储备功能降低有关。本研究的目标为评估这种常见的自身免疫性疾病与卵巢储备可能存在的负相关性。 32名原发性甲状腺功能低下并使用甲状腺素进行替代治疗的绝经前妇女被纳入了此项研究。对照组包括49名抗甲状腺抗体正常的，与HT组年龄和BMI值相仿的受试者。在窦卵泡数方面，实验组和对照组并无明显的统计学差异。与对照组相比，HT组血清抗苗勒氏管激素水平显著升高。研究结果未发现HT患者的卵巢储备相关参数受到损伤。有趣的是，研究结果显示出HT患者相比较对照组AMH的显著升高。 桥本甲状腺炎与多囊卵巢综合征或具有相同的病原学联系。因此，导致了血清AMH的升高，这是我们目前无法精确判定的。

First-trimester maternal serum metastin, placental growth factor and chitotriosidase levels in pre-eclampsia

OBJECTIVE To investigate whether the serum levels of metastin and PIGF and chitotriosidase activity early in pregnancy differ in women who develop pre-eclampsia from those who remain normotensive. STUDY DESIGN A retrospective case-control study of prospectively collected data. Thirty healthy pregnant women and 31 women with pre-eclampsia were included in the study. Serum samples were collected at 11-14 weeks and stored at -70°C. Levels of metastin, PIGF and chitotriosidase activity were measured in serum from pregnant women with subsequent development of pre-eclampsia and matched controls. RESULTS Mean maternal serum metastin (1554 ± 385 pmol/L vs 1995 ± 375 pmol/L, p<0.001) and PIGF (111.9 ± 7.0 pg/mL vs 124.9 ± 3.5 pg/mL, p<0.001) levels were significantly lower and chitotriosidase activity was significantly higher (681.6 ± 248.3 nmol/mL/h vs 527.7 ± 223.1 nmol/mL/h, p<0.01) in women who subsequently developed pre-eclampsia than in those who remained normotensive. The areas under the curve equal to 0.797, 0.831 and 0.681 (p<0.001, p<0.001 and p<0.01) for metastin, PIGF, and chitotriosidase respectively were determined for the prediction of pre-eclampsia. CONCLUSIONS Metastin and PIGF levels and chitotriosidase activity are altered in the first trimester serum of women destined to become pre-eclamptic, reflecting placental dysfunction. Metastin, like PIGF, may have a potential to be used as a first-trimester biomarker of pre-eclampsia.

Non-invasive management of acute recurrent puerperal uterine inversion with Bakri postpartum balloon

Uterine inversion is a rare and alarming obstetric emergency, the accurate management of which is very challenging to inexperienced obstetricians. Recurrence of uterine inversion is not only even more challenging, but also quite rare [1]. A 22-year-old G1 Turkish woman experienced a second-degree uterine inversion (the uterine fundus was protruding through the cervical ostium) with excessive bleeding and shock. This occurred following the spontaneous vaginal delivery of the baby and removal of the placenta by umbilical cord traction. Vaginal manual reduction of the inverted uterus was unsuccessful both in the delivery room and under general anesthesia in the operating theater. No tocolytic agent was used due to the hemodynamic instability of the patient. A laparotomy ensued and the uterus was successfully reduced as described by Huntington [2]. However despite the infusion of uterotonics, the fundal portion of the uterus softened and a dimple appeared which expanded and deepened. This resulted in a tendency of the uterus to re-invert. Accordingly, an SOS Bakri tamponade balloon catheter (Cook Medical Incorporated, Bloomington, IN, USA) was transvaginally inserted into the uterus and inflated until the dimple in the flaccid uterus disappeared. Six hundred milliliters was required to achieve this and resulted in a significant decrease in uterine bleeding with no recurrence of uterine inversion. Estimated total blood loss was 2,500 ml and four units of packed red blood cells were administered. There are few reports within the literature of uterine inversion recurrence following repositioning. The earliest report described re-inversion occurring on three occasions following manual repositioning. In that case, the uterus remained flaccid and inversion recurred every time manual compression was ceased [3]. Consequently, gauze packing of the uterus was performed and removed 28 h later without any complication. Similarly, other methods such as modified uterine compression sutures have been described to prevent recurrence of uterine inversion [1, 4]. However, in one such case, involving Cho compression sutures, a hysterectomy was required due to uterine necrosis and purulent peritonitis 11 days following the procedure [5]. The Bakri postpartum balloon has been increasingly used worldwide in the conservative management of postpartum uterine bleeding since Food and Drug Administration certification in 2006. Soleymani Majd et al. [6] first described the use of the Bakri balloon in preventing uterine re-inversion in a patient who was discovered to have uterine re-inversion 2 h after the initial replacement. In the present case, we applied a Bakri balloon during the original laparotomy to correct the inverted uterus. This was done as soon as a fundal dimple was observed, which signified the tendency of the uterus to re-invert (Fig. 1). Therefore, although uterine compression sutures may be successful in the management of recurrence of uterine B. Kaya (&) Department of Obstetrics and Gynecology, Faculty of Medicine, Near East University Medical School, Nicosia-TRNC, Mersin 10, Turkey e-mail: drbariskayaizmir@gmail.com

Maternal serum copeptin concentrations in early- and late-onset pre-eclampsia

OBJECTIVE Early-onset pre-eclampsia is primarily associated with placental dysfunction, whereas late-onset pre-eclampsia is defined as a maternal constitutional disorder. As a protein cosynthesized with vasopressin, copeptin is a potential marker of metabolic syndrome and insulin resistance, which shares similar risk factors with pre-eclampsia. The aim of this study was to investigate the copeptin levels in patients with early-onset and late-onset pre-eclampsia. MATERIALS AND METHODS A total of 80 pregnant women receiving antenatal and obstetric care were recruited. The patients were subdivided into four groups: Early-onset pre-eclampsia (n = 20), late-onset pre-eclampsia (n = 20), and two control groups of similar gestational ages for both pre-eclamptic groups (n = 20 in each group). The maternal serum copeptin levels were measured using an enzyme-linked immunosorbent assay. RESULTS The mean copeptin levels were 0.92 ± 0.57 ng/mL and 1.65 ± 0.95 ng/mL in the early-onset and late-onset pre-eclampsia groups, respectively. These values were higher compared with the control groups (0.54 ± 0.25 ng/mL and 1.15 ± 0.94 ng/mL, respectively). However, the difference was only statistically significant in the early-onset pre-eclampsia group (p = 0.011). Copeptin levels were associated only with gestational age and systolic-diastolic blood pressure. CONCLUSION Our results suggest that copeptin levels might be useful in the evaluation of the severity of pre-eclampsia. However, copeptin might be involved in early- rather than late-onset pre-eclampsia.

Maternal serum apelin and YKL-40 levels in early and late-onset pre-eclampsia

Objective: The aim of the present study is to investigate whether alterations in the serum levels of apelin and YKL-40 differ between early and late onset pre-eclampsia and whether there is a correlation between apelin and YKL-40 in women who subsequently develop early and late pre-eclampsia. Materials and methods: A total number of 80 pregnant women, 40 with normal pregnancy and 40 with pre-eclampsia, were included in the present study. Both the normal pregnant and pre-eclamptic subjects were subdivided into two groups. Serum YKL-40 and apelin concentrations were measured. Results: Mean maternal serum YKL-40 levels were both lower in women who subsequently developed early (87.45 ± 3.07 versus 103.40 ± 4.29) or late (96.43 ± 4.06 versus 99.87 ± 3.63) pre-eclampsia than those who remained normotensive. The difference was significant in early-onset preeclamptic women (p < 0.05) rather than late-onset pre-eclamptic ones (p > 0.05). Mean maternal serum apelin levels were both higher in women who subsequently developed early (8.6 ± 3.6 versus 5.7 ± 1.2) or late (9.6 ± 2.5 versus 8.1 ± 1.8) pre-eclampsia than those who remained normotensive. The difference was significant in early-onset preeclamptic women (p < 0.05) rather than late-onset pre-eclamptic ones (p > 0.05). There was a significant negative correlation between serum apelin and YKL-40 levels (r = −0.48, p = 0.001). Conclusion: Circulating levels of apelin are significantly increased in early-onset pre-eclampsia, indicating the role of apelin in the discrimination of the early-onset of pre-eclampsia. On the other hand, maternal serum YKL-40 levels are not elavated significantly, indicating that adipose-derived apelin is primarily involved in the vascular pathogenesis of early-onset pre-eclampsia than macrophage-derived YKL-40.