Burcin Karamustafaoglu Balci

The association between follicular fluid levels of cathepsin B, relaxin or AMH with clinical pregnancy rates in infertile patients.

OBJECTIVE The aim of this study was to investigate the relationship of cathepsin B, relaxin and anti-Mullerian hormone (AMH) in follicular fluid (FF) with pregnancy rates in infertility patients. STUDY DESIGN Seventy-nine infertile couples who underwent ICSI were included in the study. The FF levels of cathepsin B, relaxin and AMH were measured using ELISA kits. RESULTS The FF cathepsin B levels were statistically higher in pregnant patients compared with non-pregnant patients (0.20±0.13 versus 0.13±0.03; P<0.001). There were statistically significant differences in the total number of oocytes (10.00±6.85 versus 5.96±3.94); the mean number of M2 oocytes (8.65±5.63 versus 4.58±3.36) between the pregnant and non-pregnant patients (P<0.05). There were no significant correlations between pregnancy rates and relaxin and AMH (P>0.05). The area under the curve of cathepsin B for prediction of pregnancy was 0.662 (p=0.024, 95% Confidence Interval 0.528-0.797). CONCLUSIONS This study demonstrated that increased level of cathepsin B in FF significantly correlates with a better chance of clinical pregnancy. Further studies are needed to clarify the role of cathepsin B in the reproductive process of humans.

Incidence of an Aberrant Right Subclavian Artery on Second-Trimester Sonography in an Unselected Population: Aberrant Right Subclavian Artery on Second-Trimester Sonography

The aim of this study was to assess the incidence of an aberrant right subclavian artery (ARSA) among an unselected population during second‐trimester sonography and to review the importance of this conotruncal variant as a marker of Down syndrome.

Levonorgestrel containing intrauterine device (Mirena®) in the treatment of dyfunctional uterine bleeding; patients’ view and our experience

Abnormal uterine bleeding is a common cause for visits to gynecology polyclinics and one of the treatment options is levonorgestrel containing intrauterine device (LNG IUD; Mirena®). The aim of this study is to evaluate patient satisfaction following insertion of Mirena® in women with the indication of abnormal uterine bleeding and to share our data concerning the use of Mirena. The study population of this retrospective study consisted of women with the diagnosis of dysfuntional abnormal uterine bleeding with Mirena® inserted between 1 January 2015-31 December 2015. Information about age, obstetric and gynecologic history of the patients, histologic diagnosis of endometrial sampling, pelvic ultrasound reports were retrieved from medical records of the patients. Afterwards, interviews on phone were conducted. Patient satisfaction, complications, rate of amenorrhea, rate of expulsion or displacement, need for removal and if removed the treatment modality preferred were noted. Patient satisfaction was assessed by a scale of four as not satisfied, satisfied, very satisfied and extremely satisfied. A total of 61 Mirena® were inserted during study period and 50 patients were included in the study. We could interview with 31 patients on phone. No complication occurred related to vaginal insertion of Mirena® Twelve patients were amenorrheic, 4 patients oligomenorrheic, 4 patients were complaining of metrorrhagia (spotting). Displacement of Mirena® did not occur, however in 6.45%. of the patients Mirena® came out accidentally. Four patients wanted their Mirena® to be removed. Eight patients were “not satisfied” at all, the other patients were satisfied from the treatment. As a result, Mirena® was overall a well-tolerated treatment modality and around three-quarter of the patients with Mirena® inserted for the treatment of abnormal uterine bleeding are satisfied from the treatment.

How to calculate median Pregnancy-Associated Plasma Protein-A values to predict preeclampsia? Do We Need a Newer Formula?

Objective: Preeclampsia is one of the major issues in maternal–fetal medicine. Early risk stratification may be beneficial, so is the aim of several researches. Our goal is to investigate whether PAPP-A MoM calculated for first trimester Downs syndrome screening or MoM calculated according to Ong’s formula can be used to predict the risk of preeclampsia or do we need another method to calculate PAPP-A MoM derived from non preeclamptic cases. Study Design: For this retrospective study, data of randomly selected 150 singleton pregnant women who did not develop preeclampsia are used to create a formula to calculate median value of PAPP-A. PAPP-A values of this subgroup are plotted against gestational age and curve fit analysis is done to determine best fitted regression line to get a formula to calculate median value of our cases. PAPP-A MoM values are calculated for each subject according to Ong’s formula and our formula. We already had MoM values derived from first trimester screening. ROC curve and Delong’s pairwise comparison analyses are used to investigate which MoM value is more predictive for preeclampsia. Results: Although the area under curve value of MoM values derived from this study was the highest, DeLong’s pairwise comparison analysis showed no statistically significant difference between the three curves. Conclusion: PAPP-A MoM calculation specific to preeclampsia does not seem to be necessary; PAPP-A MoM obtained from first trimester aneuploidy scan can be used to predict preeclampsia.

Letter to the Editor: World Breastfeeding Week

Dear Editor, Due to World Breastfeeding Week, it is planned to support and encourage breastfeeding and to protect breastfeeding women between August 1 and 7, 2015. World Alliance for Breastfeeding Action (WABA) is a global network of individuals and organizations endeavoring to highlight the significance of breast-milk and to make breastfeeding widespread. WABA has announced its goals for 2015. The most important two goals are to support women being able to breastfeed in workplace and to encourage governments to establish laws protecting mothers. Since 2001, World Health Organization has been recommending exclusive breastfeeding up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond. Most of the mothers want to breastfeed for a long time for the purposes of feeding their babies, protecting them against infections and having the emotional satisfaction of breastfeeding. Turkish Population and Health Survey 2013 showed that 33.9% of 20–23-month-old babies were breastfed and the mean lactation period for all children born within three years before 2013 was 16.7 months. According to the data of the same survey, 18% of the deliveries in Turkey occurred less than 24 months after the previous delivery. According to these data, we should observe a considerable amount of pregnant women in the clinics who have a child below 2-year-old they are breastfeeding. It is very critical to inform mother for the continuation or discontinuation of lactation when a breastfeeding woman gets pregnant. In Turkey, women tend to discontinue lactation when they get pregnant. Atar Güler et al. found that 26 of 102 pregnant women, whose pregnancy interval (the period between previous delivery and the onset of following pregnancy) is less than 24 months, discontinued lactation due to the pregnancy. At this point, gynecologists and obstetricians may support the discontinuation of lactation due to the concern that lactation during pregnancy may have risks for fetus and/or mother. However, the studies show that miscarriage and preterm labor risks do not increase in pregnancies during lactation. In cases where pregnancy coincides with lactation, it is unclear if continuation of lactation causes the fetal growth to slow down. When birth weights of babies delivered by women continuing lactation during pregnancy were compared with those delivered by women discontinued lactation during pregnancy, a study carried out on 505 pregnant women found no statistically significant difference while another study carried out on 61 pregnant women found statistically significant difference. No guide has been found in the literature showing the daily needs of lactating pregnant women for calories, protein, vitamin and mineral. On the other hand, it should be taken into account that energy, protein, vitamin, mineral and water needs of both pregnant and lactating women increase. Although the data in the literature indicates that lactating during pregnancy is safe, current studies cannot prove that lactation during pregnancy is either harmful or useful for mother/fetus/baby. Today, where there are many efforts to make breastfeeding widespread and to extend lactation period, it is possible that we come across mothers more frequently who prefer to continue lactation during pregnancy. Therefore, gynecologists and obstetricians should have up-to-date knowledge about the outcomes of lactation in cases where pregnancy and lactation coincide.

Postnatal Diagnosis of 22q11.2 Deletion Syndrome in Fetal Megalourethra

22q11.2 deletion syndrome is the most common micro deletion syndrome, with an estimated prevalence of 1 per 4000 live births.1,2 The main clinical phenotypes associated with 22q11.2 deletion syndrome are velocardio facial syndrome, DiGeorge syndrome, conotruncal anomaly face syndrome, Cayler cardiofacial syndrome, and CATCH 22 syndrome (cardiac defects, abnormal facial features, thymic hypoplasia, cleft palate, and hypocalcemia),3 which were thought to be distinct disorders, but are now identified as different manifestations of 22q11.2 deletion syndrome.3 The features associated with 22q11.2 deletion syndrome include congenital heart diseases (in particular, conotruncal anomalies), a typical facial phenotype, palatal abnormalities, congenital hypocalcemia, and immune deficiency.4 Even though urinary tract anomalies are also frequent in patients with this microdeletion, with percentages ranging from 31% to 80%,5,6 physician awareness is low.7 In the previous English literature on prenatal diagnosis of 22q11.2 deletion syndrome, cardiovascular anomalies generally led to the diagnosis,1,4,7–9 except 3 cases reported by Goodship et al,7 which predominantly had urinary tract anomalies. We report a case of 22q11.2 deletion syndrome presenting with urinary tract anomalies on antenatal sonography. A 35-year-old woman, gravida 1, para 0, was referred to our clinic for first-trimester screening. Her medical and family histories were unremarkable except for her diabetic father. She reported no drug use. A first-trimester scan at 11 weeks’ gestation revealed no major structural anomalies; nuchal translucency was within normal limits (1.4 mm); the nasal bone was visible; but the longitudinal diameter of the bladder was 7 mm. A combined test showed low risk for trisomy 13, 18, and 21. Her maternal blood human chorionic gonadotropin level was 0.6916 multiple of the median, and her pregnancy-associated plasma protein A level was 1.5449 multiples of the median. At 18 weeks’ gestation, sonography revealed megalourethra (Figure 1A), megacystis (Figure 1B), and bilateral pyelectasis. The fetus was male. The penile urethra was completely dilated, and the absence of a keyhole sign and ureterocele were noted during this examination. Amniocentesis was offered and performed because of the megacystis. The karyotype was 46,XY. Sonography was repeated at 19 weeks’ gestation by a multidisciplinary team, including a pediatric urologist, a medical geneticist, and perinatologists. At 19 weeks’ gestation, both kidneys had increased renal echogenicity, and the bladder wall measured 4 mm. Fetal echocardiography was performed at 19 weeks’ gestation; the 4-chamber, 5-chamber, and 3-vessel and trachea views were normal, and an aberrant right subclavian artery was not observed. The thymus was present on the 3-vessel and trachea view. During this scan, megalourethra was noted, but subsequent evaluations did not reveal it. Bilateral pyelectasis and a dilated bladder with a trabeculated and thickened wall were constantly observed. A male neonate was born by elective cesarean delivery at 38th weeks’ gestation with a birth weight of 3510 g, a length of 53 cm and a head circumference of 36 cm. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. He was hospitalized at 7 days of age for repeated hypocalcemic seizures with low parathyroid hormone levels. Serial electroencephalograms were abnormal. After 3 days of intravenous calcium administration, oral calcium replacement