And Yavuz

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

Abstract 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.

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.

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.

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

Abstract 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.

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

Abstract 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.

An unusual complication of vesicoamniotic shunt: coiling of the shunt around lower extremity associated with dislodgement

Introduction Posterior urethral valve (PUV) is the most common aetiology of foetal obstructive uropathy with an incidence of around 1/5000 to 1/8000 pregnancies (Brown et al. 1987). Untreated PUV is associated with increased neonatal morbidity and mortality due to renal dysplasia and pulmonary hypoplasia (Freedman et al. 2000). Vesicoamniotic shunting (VAS) is a procedure that aims to reduce intraluminal pressure of the foetal bladder with subsequent involvement of the upper urinary tract and prevent pulmonary hypoplasia due to secondary oligohydramnios. In previous reports, iatrogenic anterior wall defects secondary to placement of shunts has been reported (Gehring et al. 2000; Irwin & Vane 2000). Here, we report an unusual complication of VAS, coiling of the shunt around foetal lower extremity associated with dislodgement.

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.

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.

EP01.01: Reliability of cavum septum pellucidum volume measurements during second trimester ultrasonography in structurally normal fetuses

Objectives: Cavum septum pellucidum (CSP) is an important intracranial structure that is necessarily visualised during routine second trimester sonography. A small or a large CSP may suggest abnormal cerebral development. Therefore, determination of CSP volumes can be useful. However, consistency of sonographic measurements for this relatively small structure is a concern. For this purpose, we sought to assess the reliability of CSP volume measurements with three-dimensional ultrasound between 19–24 weeks of gestational age in structurally normal fetuses. Methods: Three-dimensional Virtual Organ Computer-aided Analysis (VOCAL) software was used to calculate the CSP volume from transabdominal multiplanar datasets obtained during 99 consecutive normal fetal ultrasound examinations within a single unit. Agreement among 3 independent observers with different experience levels of ultrasonography (year 2 obstetrics and gynecology resident, year 2 maternal-fetal medicine fellow, and maternal-fetal medicine specialist) was evaluated, using absolute agreement intraclass correlation coefficients (ICC) and 95% confidence intervals (CI). Results: Measurement of CSP volume was possible in all of the fetuses by all examiners. Interobserver agreement between fellow and specialist was relatively high (ICC, 0.78; 95% CI, 0.70–0.85), whereas limited ultrasound experience (resident) was associated with fair agreement with other observers (ICC for resident and specialist, 0.50; 95 CI%, 0.29–0.65 and ICC for resident and fellow, 0.57; 95% CI, 0.38–0.71). Conclusions: Three-dimensional ultrasound CSP calculations using VOCAL software between 19–24 weeks of gestational age seem feasible, but are reliable only when evaluated by an examiner with particular fetal sonography experience.

Thickness measurement of fetal epicardial adipose tissue in structurally normal fetuses between 24 and 28 weeks of gestation

Objective: Ultrasonographic measurement of epicardial adipose tissue (EAT) is carried out frequently adults as an indirect indicator of lipogenesis and metabolic syndrome. However, the information on the measurement of this tissue in fetus is limited. Our aim is to determine the measurement values of fetal EAT thickness according to the weeks in non-complicated pregnancies. Methods: Thirty-nine pregnant women, who admitted to maternity clinic between 24 and 28 weeks of gestation for routine follow-up and who had no problem in their fetal and maternal follow-ups, were included in our study. Fetal EAT thickness was measured in the Perinatology Clinic. The relationship of fetal EAT measurements with the week of gestation was evaluated statistically. Results: Maternal age (p=0.33) and body mass index (p=0.88) according to the weeks of gestation were similar. Median [interquartile range] fetal EAT thicknesses at 24+, 25+, 26+ and 27+ weeks of gestation were 1.29 mm [1.267–1.320], 1.295 mm [1.275–1.305], 1.325 mm [1.297–1.355] and 1.34 [1.330–1.355], respectively. There was a significant difference only in the measurements between 25 and 26 weeks of gestation (p=0.048). Conclusion: Fetal EAT thickness increases in direct proportion to the week of gestation. Proportionately, the highest increase is between 25 and 26 weeks of gestation.