Ahmet Eser

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

Abstract 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.

Early amniotomy after dinoprostone insert used for the induction of labor: a randomized clinical trial

Abstract Purpose: We assessed whether early amniotomy, after ripening with a dinoprostone insert, reduces the duration of labor or increases the rate of delivery within the following 24 h. Methods: A prospective randomized controlled study was conducted on 200 consenting, term pregnant women at the Zeynep Kamil Maternity and Children’s Training and Research Hospital. Each participant received vaginal inserts of 10 mg dinoprostone. The women were randomly assigned to one of two groups: early amniotomy (artificial rupture of membranes when cervical dilation was at 3 cm) or standard amniotomy (the membranes were left to rupture spontaneously). The primary outcome measures were the time from induction to delivery, and the proportion of women who delivered within 24 h. Results: The median time interval from induction to delivery (13.72 h compared to 22.73 h) was significantly shorter for women who underwent early amniotomy (p < 0.05). The frequency of vaginal delivery within 24 h was higher in women with early amniotomy (89% compared with 45% in the standard amniotomy, p < 0.05). Conclusions: Early amniotomy, after ripening with a dinoprostone insert, is a safe and efficient method for speeding up delivery times without increasing caesarian rates during labor inductions.

Planned cesarean hysterectomy versus modified form of segmental resection in patients with placenta percreta

Abstract Objectives: The aim of this study was to compare some clinical characteristics of two different management alternatives in pregnants with placental invasion anomalies. Methods: We conducted a single-center retrospective study of all patients who delivered with invasive placentation between January 2016 and May 2017. We included only the patients with placental invasion anomaly and planned cesarean section. Results: Fifty-one pregnants met the inclusion criteria. Cesarean hysterectomy was performed in 29 patients and segmental resection in 22. Major intraoperative and postoperative complications were comparable between the two groups. There were significant differences between the groups with regard to gravidity, pre- and post-operative hemoglobin concentrations, number of packed red blood cell transfused, and operation time (p < .05). Conclusions: An initial fertility conserving surgical procedure is an option in patients with extensive invasive placentation with lesser transfusion requirement and shorter operative time compared to cesarean hysterectomy.

Predictive value of some hematological parameters for non invasive and invasive mole pregnancies.

Abstract 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.

Validation of the Turkish Version of the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) in Turkish-Speaking Women.

Introduction The Sexual Health Outcomes in Women Questionnaire (SHOW-Q) is designed to evaluate the sexual life of women for satisfaction, orgasm, desire, and pelvic problem interference. The SHOW-Q is important for evaluating worsening of sexual life for patients with pelvic problems and the management of these women to improve their sexual life. Aims To validate the Turkish versions of the SHOW-Q for Turkish-speaking women. Methods The Turkish version of the SHOW-Q was generated by two independent professional English-to-Turkish translators. The translated version of the SHOW-Q was reverse translated by two bilingual translators whose native language was English. Women with at least one symptom related to pelvic problems (n = 71) and those with no symptoms (n = 38) were included in the present study. Main Outcome Measures Test-retest reliability analysis, content-face validity, internal consistency reliability, item-total correlations, convergent validity, construct validity, and factorial validity were performed to assess the psychometric properties of the Turkish versions of the SHOW-Q. Results Test-retest reliability demonstrated good correlation for all subscales. Cronbach α values ranged from 0.735 to 0.892 and indicated high internal consistency. There was a strong correlation for the corresponding subscales between the SHOW-Q and the Female Sexual Function Index. The mean score of each SHOW-Q subscale showed significant differences between symptomatic and asymptomatic patients. Conclusion The Turkish version of the SHOW-Q is a valid and reliable instrument that can be used to evaluate the sexual life of Turkish-speaking women with different pelvic problems.

The outcomes of controlled ovarian hyperstimulation/intrauterine insemination in patients with unilateral tubal occlusion on hysterosalpingograph

Objective: The aim of the present study was to evaluate the pregnancy rates of intrauterine insemination (IUI) and controlled ovarian hyperstimulation (COH) in patients with one-sided tubal occlusion on hysterosalpingography (HSG). Materials and Methods: Patients who underwent COH/IUI were enrolled into this retrospective cohort study. The patients with one-sided tubal occlusion diagnosed under HSG who met the inclusion criteria were accepted into the study group. The control group consisted of patients with unexplained infertility. The outcomes of COH/IUI were compared between the study and control groups. Results: Ninety-seven patients in the study group (n=44) and control group (n=53) who underwent COH/IUI treatment were included into study. The biochemical, clinical, and ongoing pregnancy rates were similar between patients with unilateral occlusion diagnosed under HSG and those with unexplained infertility. The spontaneous pregnancy rate within one year was higher in patients with normal HSG than in patients with unilateral tubal occlusion, but the difference did not show statistical significance. Conclusion: Infertile patients with one-sided tubal occlusion in HSG can be managed as with patients with unexplained infertility and normal HSG findings. In addition, COH/IUI may be considered as the first-line treatment option in the management of these patients.

Evaluation of risk factors for the recurrence of ovarian endometriomas

OBJECTIVES To evaluate the risk factors for the recurrence of ovarian endometrioma after laparoscopic cystectomy. STUDY DESIGN Reproductive aged patients who underwent laparoscopic ovarian endometriotic cystectomy and with histopathologically confirmed diagnosis of ovarian endometrioma were evaluated retrospectively. Histopathologic specimens were reevaluated and histopathologic characteristics of ovarian endometriotic cysts (thickness of cyst wall, thickness of fibrosis [ToF], thickness of ovarian tissue, the number of follicles per cyst, the depth of penetration [DoP] of endometrial tissue into the cyst wall) were determined. Along the determined histopathologic findings, demographic characteristics (age at surgery, number of pregnancies), clinical symptoms (dysmenorrhea, infertility), intraoperative findings (revised American Society for Reproductive Medicine [rASRM] stage), imaging features (bilaterality, cyst diameter), and biochemical parameters (Ca125, Ca19.9, Ca15.3) were evaluated as possible risk factors for the recurrence of endometrioma. The variables with p<0.2 in univariate analysis were introduced into regression analysis to determine the risk factors for recurrence. RESULTS There were statistically significant differences in age group (≤35 years and >35 years), the ToF and DoP between patients with recurrence and those with no recurrence. In Cox regression analysis, age ≤35 years and DoP were significant risk factors for presence of recurrence. DoP, ToF, preoperative cyst diameters in ultrasonographic examination were inversely correlated with recurrence interval. In multivariate regression analysis, the DoP was found the only significant risk factor for the recurrence interval. 1.2mm of DoP was found as the optimum cut off value for presence of recurrence according to Youden index criteria in ROC curve analyze. The sensitivity (62.9%), specificity (75%) were obtained at the cut off value of 1.2mm for DoP. CONCLUSION Histopathological features of ovarian endometriotic cyst may have important roles on predicting the recurrence of the endometrioma. Predicting the recurrence risk of particular patient is very important in future management of the disease. Knowing the recurrence risk of an endometrioma will help in deciding the optimal treatment modalities for each individual patient. High risk patients should be offered appropriate treatments according to the clinical status without delay and low risk patients should be protected from overtreatment.

Dual trigger with gonadotropin-releasing hormone and human chorionic gonadotropin for poor responders

Objective: To compare metaphase II (MII) rate, fertilization rate, and embryo quality with dual trigger gonadotropin-releasing hormone agonist (GnRH) and normal dose human chorionic gonadotropin (hCG) versus a normal dose hCG trigger in antagonist intracytoplasmic sperm injection (ICSI) cycles of poor ovarian responders. Material and Methods: Patients defined as poor ovarian responders according to the Bologna criteria who underwent ICSI with GnRH antagonist protocol and triggered with dual trigger or hCG alone for oocyte maturation. Main outcome measures were MII rate, fertilization rate, and embryo quality. Results: Total gonadotropin doses and E2 levels on trigger day were higher in the hCG trigger group. There were no significant differences with regard to implantation rate (p=0.304), biochemical pregnancy rate (p=0.815), clinical pregnancy rate (p=0.378), and ongoing pregnancy rate (p=0.635) between the groups. Conclusion: Dual trigger of oocyte maturation with GnRH agonist and normal dose hCG in poor responders does not demonstrate improved oocyte maturation, clinical pregnancy, and ongoing pregnancy rates.

Response to letter to the editor “Early amniotomy after dinoprostone insert used for the induction of labor”

I am very pleased that my research was criticized with interest. We would like to respond to the recent “letter to the editor” by Abbas et al. If you had conducted a similar research in an earlier published article, you would have to increase your sample size. But, we did not find any researches that could be a reference for our research. Only in Macones’ study, 7–8% of women in each group were induced with dinoprostone [Cervidil] [1]. It is obvious that the number of patients in our study is more than that. Although we have taken this study as a reference in our manuscript; we have not mentioned the samples size based on it. In fact, the principles of randomized controlled trials (RCTs) have not been generally accepted. You are right, it would be better to specify in the text which patients were excluded from the study. There were 13 cases discovered to have cephalopelvic disproportion (CPD) and delivered by cesarean section. But they were not macrosomic babies. I wonder how such an idea got before Abbas did not see the data. There was only one macrosomic baby (4522 g) without gestational diabetes. We reported the rate of Apgar score less than seven as one of the secondary outcomes; and we did not miss to present this outcome. You can see these results in Table 3. Zeynep Kamil Education and Research Hospital is a reference hospital for follow-up and management at high-risk pregnancies. The number of births is between 700 and 800 every month. It is the biggest hospital for gynecology and obstetric in Istanbul. Majority of births are in high-risk pregnancies. Author stated that abnormally distributed data should be presented as median (IQ Range). Nominal or ordinal data which are not measurement data can be described as median (IQ Range). However, a scale or measurement data may be described as both mean SS and median (IQ Range). We used M-WU test because the data distribution was not normal and did not meet the assumptions of the t-test. Most of articles in respective and high impact factor journals use mean SS for abnormally distributed data. It would be better to report the median and IQR. NORMALITY and CONTINUITY are different concepts in mathematics and statistics. One of them determines the type of difference analysis results, other determines type of data. In Table 2, the cesarean delivery indication variables were compared with chi-square. Its notation was given under the table.