Baris Kaya

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.

Gestational diabetes mellitus in patients receiving long-term corticosteroid therapy during pregnancy

Abstract Aim: Little data exist on the impact of chronic low dose corticosteroid therapy during pregnancy on gestational diabetes mellitus (GDM). Method: We compared 25 pregnant women receiving long-term (>4 weeks) corticosteroid for newly diagnosed idiopathic thrombocytopenic purpura (ITP) (study group) and 108 normal pregnant women (control group) in this case-control study. Main outcome measures were 1-h, 50-g and 3-h, 100-g glucose tolerance tests (GTTs). Women in both groups were also screened with 75-g GTT 6 weeks after delivery. Results: The mean duration of corticosteroid therapy was 9.8±4.9 (range 6–25) weeks. Compared with controls, study group patients had a greater prevalence of diagnosed GDM (24.0 vs. 2.8%, P=0.01). Of these patients, 83.3% were diagnosed with GDM at 16 weeks gestation. An impaired 75-g GTT was also more frequent in the study group (P=0.01). Conclusion: Our findings suggest that long-term corticosteroid therapy may be associated with the development of diabetes in pregnant women and early GTT should be performed in pregnant women on corticosteroid therapy.

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。

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

Serum YKL-40 levels are altered in endometriosis

Abstract Endometriosis is traditionally defined as the presence of endometrial glands and stroma in ectopic locations, especially the pelvic peritoneum, ovaries and rectovaginal septum. YKL-40, a new biomarker of inflammation, is secreted by activated macrophages and neutrophils in different tissues with inflammation. Serum concentrations of YKL-40 are elevated in patients with diseases characterized by inflammation. We aimed to investigate the possible association between serum YKL-40 levels and endometriosis. A total number of 88 women were recruited for this case–control study. About 53 patients with surgically proven endometriosis were included, while 35 patients without endometriosis comprised the control group. Patients were classified as having minimal, mild, moderate and severe disease in accordance with the severity. Two new groups were formed by combining patients with minimal and mild disease (Stage 1–2) and with moderate and severe disease (Stage 3–4). Serum YKL-40 levels were statistically higher in the endometriotic group compared to control group (p:0.001). YKL-40 levels were significantly higher in Stage 3–4 group compared to Stage 1–2 group (p values 0.001) as well. Correlation analysis revealed a positive correlation between serum YKL-40 levels and the stage of the disease. YKL-40 may be utilized as a marker for determining the severity of endometriosis.

Maternal serum autotaxin levels in early- and late-onset preeclampsia

ABSTRACT Purpose: We aimed to compare the serum autotaxin levels in early- and late- preeclamptic and healthy pregnant patients at a university hospital. Methods: A total of 55 singleton preeclamptic women who delivered at Cerrahpasa Medical Faculty were included in the study. The patients were subdivided into two groups: early-onset preeclampsia (n = 31) and late-onset preeclampsia (n = 24). Demographic and clinical data were compared between early-onset and late-onset preeclamptic patients. The control group was composed of 32 healthy pregnant patients. Results: The mean autotaxin levels were 1.16 ± 0.97 and 0.7 ± 0.35 ng/ml in the early- and late-onset preeclampsia groups, respectively. Autotaxin levels were significantly higher in early-onset preeclampsia group compared with late-onset preeclampsia group. Autotaxin levels were found to be significantly higher in preeclamptic patients compared with control group. Serum autotaxin levels showed a significant positive correlation with maternal systolic, diastolic blood pressures and uric acid levels. Conclusion: Autotaxin might be a promising marker for detecting early-onset preeclampsia. However, further studies are necessary to confirm this hypothesis.

Is there yet a role for internal iliac artery ligation in obstetric hemorrhage with the current gain in popularity of other uterus sparing techniques

Abstract Purpose: To evaluate the success rates and subsequent fertility outcomes of internal iliac artery ligation (IIAL) in uterine atony (primary ligated and secondary added to other uterus sparing techniques), retroperitoneal hematoma, and placenta adherent abnormalities. Material and methods: Fifty two women who underwent IIAL for different causes of postpartum hemorrhage were retrospectively evaluated. Results: Among 26 women with intractable uterine atony, 12 had primary, and 14 secondary IIAL, due to ongoing bleeding following the B-Lynch suture or the Bakri balloon tamponade. The success rates were 91% and 71.4% in the primary and secondary IIAL groups, respectively. The success rates of IIAL in 12 women with placental adhesion abnormalities and another 12 with obstetric retroperitoneal hematoma were 75% (9/12) and 83% (10/12) respectively. Nine (17%) hysterectomies were performed after failure of IIAL. Two maternal deaths occurred in our study. The rate of achieving pregnancy was not significantly different between the groups. Conclusions: Hysterectomy rates might be decreased with the addition of IIAL provided that other uterus sparing techniques; B-Lynch or the Bakri balloon was to fail separately. IIAL can save lives in severe obstetric retroperitoneal hematoma. IIAL does not affect fertility even it is combined with other uterus sparing techniques like the Bakri balloon and B-Lynch suture.

The Bakri balloon implementation during cesarean section without switching to the lithotomy position

Abstract Bakri balloon implementations for the conservative management of postpartum hemorrhage (PPH) have become more popular in the recent years. The procedure may be regarded as simple, however, it can become a challenging method considering an excessive bleeding patient where there is a race against time. In our daily practice we do not usually use the lithotomy position except for few conditions such as placenta previa, where the lithotomy position is necessary to apply a Bakri balloon during PPH during a cesarean section. Here we would like to present a woman with uterine atony and fundal placenta accreta bleeding, managed with the Bakri balloon without switching to the lithotomy position for the first time in the literature. The bleeding was evaluated successfully with this new method, however, a cesarean hysterectomy was necessary to achieve hemostasis despite the addition of a bilateral uterine artery ligation at the end. The decision to add a vessel ligation to the inflated Bakri balloon should be assessed carefully as uterine artery ligation may be time consuming due to effort of avoiding puncturing the balloon. On the other hand, internal illiac artery ligation may be more advantageous if the surgeon is experienced.

Paravesical and broad ligament hematoma after vaginal delivery

Abstract The management of puerperal hematomas after normal delivery has always been a challenging issue for obstetricians. Vulvar, vulvovaginal, or paravaginal hematomas are common; by contrast, retroperitoneal hematomas after normal delivery are uncommon and can be life-threatening. There are only few case reports about retroperitoneal hematomas in the literature and no standard management has yet to be established. Although pelvic arterial embolization has become a rational and popular method in the management of puerperal hematomas in recent years, it can only be performed if the patient is stable and interventional embolization unit is available. Moreover, the patient with hematoma usually presents with symptoms of shock; hence, rapid intervention is necessary. Considering the suggestions in the literature, management options of retroperitoneal hematomas include conservative management, incision and drainage of the hematoma, pelvic arterial embolization, and hysterectomy. Internal iliac artery ligation is a common mode of puerperal hematoma treatment; however, it has yet to be reported as a treatment modality in retroperitoneal puerperal hematoma. Thus, I present a very rare case of retroperitoneal hematoma after normal delivery, presenting with the symptoms of shock. Visualization and dissection of the retroperitoneal space was challenging in the hematoma site; however, the bleeding was successfully controlled with internal iliac artery ligation. Recovery of the patient was uneventful.

Concurrent endometrial adenocarcinoma and an early pregnancy loss

Even though endometrium cancer is the most common cancer of the female reproductive tract, cancer occurs very rarely during pregnancy. A 45-year-old gravida 4 para 3 patient presented with abnormal vaginal bleeding and 8 weeks of pregnancy. The ultrasonographic evaluation revealed a disordered gestational sac with an 8 weeks embryo with no heart beat. The pathological examination of the dilatation and curettage material revealed chorionic villi and fetal material with a small focus of well-differentiated endometrial adenocarcinoma (Fig. 1). The patient completed her fertility and agreed with the decision of her family; a complete surgical staging procedure was performed. Final pathology report showed grade 1 FIGO stage 1A endometrial adenocarcinoma. To our knowledge, there have been 20 cases of first trimester pregnancy concurrent with endometrial carcinoma reported in the literature [1]. In most of these cases, the diagnosis was made by D&C for incomplete or missed abortion (61 %) [2]. Different theories have been proposed to explain the unfavorable hormonal milieu of pregnancy for endometrial cancer growth. For example, Risberg et al. pointed out that with concomitant secretory endometrium, the malignant regions must be progesterone refractory. Possibly, carcinoma arises in these foci and is only responsive to estrogen, while the rest of the endometrium continues to be responsive to both estrogen and progesterone [3]. Another possibility of this event is that the endometrial cancer had been there—but in early phase— when pregnancy took place, so the progesterone effect is too late to intervene. Cancers associated with pregnancy are typically limited to a small focus and when more extensive they tend to only invade superficially into the myometrium, as in our patient. Many different etiological theories have been reported about endometrial cancer concurrent with pregnancy. For the first 3 weeks following implantation of pregnancy, hCG promotes production of progesterone by ovarian corpus luteal cells [4]. Hyperglycosylated hCG binds and antagonizes TGFß receptors on the cytotrophoblast cells, the cells that make hyperglycosylated hCG [4]. A number of observations show that hyperglycosylated hCG acts on cancer and pregnancy implantation through antagonizing TGFß [4]. However, the molecular basis of the relation between endometrium cancer and pregnancy still remains obscure. In future studies, the increased understanding of the variating roles of hCG may allow us to build a link between pregnancy and endometrium ca. Not only gestational trophoblastic neoplasia, but also coincidental endometrial cancer is a rare but possible event in a case of first trimester pregnancy loss. The routine histological examination of the curettage specimens for all first trimester pregnancy losses, independent of the age of the patient, should be encouraged. A. Akil A. Karabay Department of Obstetrics and Gynecology, Sehitkamil State Hospital, Gaziantep, Turkey