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Acute increase in plasma D-dimer level in ovarian torsion: an experimental study

BACKGROUND Torsion of the ovary is a rare but serious cause of gynecologic surgical emergency. Specific laboratory markers that support the preoperative diagnosis of ovarian torsion are not currently available in the clinical routine. The aim of this study was to investigate the diagnostic value of plasma D-dimer level as an early indicator of ovarian torsion in an experimental rat ovarian torsion model. METHODS Sixteen female adult Sprague-Dawley rats were used for this controlled experimental study. Eight rats in the sham operation group (Group I) underwent a surgical procedure similar to Group II but the ovary was not occluded. In Group II (eight rats), a torsion model was created by using atraumatic vascular clips just above and below the right ovary for a 2-h period of ischemia. Right ovaries were surgically removed at the end of the procedure in each group. Blood was sampled before and after operation to assess plasma D-dimer levels. The main outcome measure was ovarian histopathologic findings scores and plasma D-dimer levels. RESULTS There was no significant difference in pre-operative plasma D-dimer levels (0.5963 ± 0.2047 mg/l in Group I, 0.6344 ± 0.1348 mg/l in Group II, P = 0.815, Mann-Whitney U-test). However, mean plasma D-dimer value for Group II was significantly higher than that in the control group (1.2267 ± 0.3099 versus 0.6213 ± 0.2346 mg/l, respectively, Mann-Whitney U-test, P < 0.001), following 2 h of ovarian torsion. Ovarian tissue damage scores were also statistically significantly different among groups. CONCLUSIONS If the observations made in a rat model are extended to humans, plasma D-dimer measurement may be a valuable parameter in the early diagnosis of ovarian torsion.

Carbon dioxide pneumoperitoneum induces systemic oxidative stress: a clinical study

OBJECTIVE To investigate the effect of carbon dioxide pneumoperitoneum on systemic oxidative stress by using serum oxidative stress markers (ischemia modified albumin (IMA), malondialdehyde (MDA), total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI)) and to compare their effectiveness at clinically accepted safe intra-abdominal pressure levels (<12 mmHg). STUDY DESIGN A total of 33 consecutive patients who had a unilateral ovarian cyst were enrolled for this prospective clinical study. All women underwent a laparoscopic ovarian cystectomy procedure. Venous blood was collected from patients preoperatively, 10 min after induction of anesthesia and 30 min after insufflation. Preoperative, 10(min), and 30(min) serum IMA, MDA, TOS, OSI and TAS levels were compared. RESULTS The mean age was 29.3 ± 6.4 and the range of operation time was 45-80 min. The mean serum IMA levels showed a significant increase 30 min later from CO(2) insufflation (p<0.05). Significant alterations were not observed in serum MDA, TOS, OSI or TAS levels. CONCLUSIONS Laparoscopic surgery causes systemic ischemia and this ischemic effect can be revealed by measuring serum ischemia modified albumin. IMA is more sensitive than MDA, TOS, OSI and TAS in early detection of systemic oxidative stress.

Stage IV C prolapse in pregnancy

⁎ Corresponding author. KTU Tip Fakultesi, Farabi Hastanesi, Kadin Hastaliklari ve Dogum ABD, 61080 Trabzon, Turkey. Tel.: +90 462 3775869; fax: +90 462 3250518. E-mail address: drsuleymanguven@yahoo.com (S. Guven). Prolapse is a common gynecologic condition, yet prolapse during pregnancy is rare, with an estimated incidence of 1 case per 10 000– 15 000 deliveries; the complications of this condition include patient discomfort, urinary tract infection, acute urinary retention, abortion, preterm labor, andmaternal death. Standardmanagement of prolapse in pregnancy is still being debated [1]. In the present paper, 2 cases of uterine prolapse in pregnancy are reported, with review of the related literature. A 21-year-old gravida 4, para 3 was admitted to Sason Government Hospital with complaints of prolapse at 20 weeks of gestation. Her first delivery—at 17 years of age—ended, after a long labor and difficult delivery, with application of uterine fundal pressure. Other deliveries were uneventful at term. The patients medical and surgical histories were unremarkable, and there was no history of pelvic trauma, prolapse, or stress incontinence during or after the previous pregnancies. During the current pregnancy, she noted a feeling of heaviness at 10 weeks of gestation, and examination by local general practitioner revealed cervical descent to the level of the vaginal introitus. During the pregnancy, the cervix prolapsed out of the vaginal vault. Upon admission, clinical examination revealed stage IV prolapse, with point C as the leading edge according to the pelvic organ prolapse quantification (POP-Q) staging system (Fig. 1). The patient was managed conservatively (bed rest in a slight Trendelenburg position and 2 weeks of antibiotic therapy for urinary tract and cervical infection). At 26 weeks of gestation, she delivered an 860-g live male fetus. Shortly after delivery, the neonate died because of prematurity. Stage IV prolapse, with point C as the leading edge according to the POP-Q staging system, was evident at birth and 6 weeks postpartum. Pelvic reconstructive surgery was scheduled. A 36-year-old gravida 3, para 2 was admitted at 16 weeks of gestation following prolapse. Four years earlier, her first delivery was uneventful at term. The prenatal period of her second pregnancy was uncomplicated. The postpartum period immediately after vaginal delivery of her second child was complicated by prolapse. She was discharged from hospital 5 days later in good health and with complete resolution of prolapse. Further examination 6 weeks postpartum showed no evidence of prolapse. During the current pregnancy, 6 months after her second delivery, she was admitted with the same complaint. Upon admission, clinical examination revealed stage IV prolapse, with point C as the leading edge according to the POP-Q staging system (Fig. 1). The patientwas conservatively treatedwith bed rest. Stage IV C prolapsewas not resolved throughout the pregnancy. At 39 weeks of gestation, she delivered a 3300-g live female infant. Stage IV prolapse, with point C as the leading edge according to the POP-Q staging system, was evident at birth and 6 weeks postpartum. Pelvic reconstructive surgery was scheduled. The etiology of prolapse is multifactorial. Factors—including childbirth trauma, congenital weakness in pelvic fascial support, pelvic neuropathies, and large uterine and ovarian tumors—that result in increased intra-abdominal pressure and pelvic trauma can result in pelvic organprolapse.Moreover, thephysiologic changes of pregnancy— in terms of cervical elongation and hypertrophy—and the physiologic increases in cortisol, progesterone, and relaxin, which lead to a concomitant softening and stretching of the pelvic tissues, can also contribute to prolapse [1]. Management options for patientswho experience uterine prolapse in pregnancy have varied little over the years. Conservative management with genital hygiene and bed rest in a slight Trendelenburg position to enable prolapse replacement should be considered the foremost treatment option. These precautions protect the cervix from trauma/desiccation and reduce the incidence of preterm labor. Vaginal pessary application to protect the cervix may be considered beneficial, although displacement is common. Of interest is the recent report of a laparoscopic modified Gilliam suspension during early pregnancy, when other conservative solutions fail or when prolonged bed rest is impossible [2]. In cases of prolapse during pregnancy, normal vaginal delivery can be achieved. Although operative vaginal delivery with forceps or hysterostomatomy is advised, continued stretching of the lower segment to the point of uterine rupture due to cervical dystocia has also been reported [3]. In this situation, cesarean delivery becomes the inevitable choice for women with a thick, edematous, trapped, and irreducible cervix. Cesarean hysterectomy with subsequent suspension of the vaginal cuff might be a therapeutic option for women who have completed their families [4]. Obstetricians should be aware of prolapse during pregnancy and should bear in mind that it may lead to complications such as preterm delivery, prematurity, and urinary tract and cervical infections. However, the optimal current management guidelines for this rare condition are unclear.

Meperidine versus valethamate bromide in shortening the duration of active labor

To compare the efficacy and safety of meperidine hydrochloride and valethamate bromide against placebo in shortening the duration of active labor.

Thoracopagus Conjoined Twins: A Case Report

Objective. Conjoined twin is a rarely seen congenital anomaly together with severe mortality and morbidity. The more common types of conjoined twins include the thoracopagus type, where the fusion is anterior, at the chest, and involves the heart. We are reporting one case of conjoined thoracopagus twins diagnosed by ultrasonography at 11 weeks. Case Report. In a multigravid pregnant woman who has been admitted to our clinic with a diagnosis of conjoined twins, thoracopagus, by ultrasonography at an 11-week gestation, termination of the pregnancy was performed. Conclusion. Making an early diagnosis with ultrasonographic examination gives the parents a chance to elect pregnancy termination.

Life-threatening intraabdominal bleeding after oocyte retrieval successfully managed with angiographic embolization

OBJECTIVE To report the first case of massive intraabdominal hemorrhage after transvaginal ultrasonographically guided oocyte retrieval that was successfully managed with angiographic uterine artery embolization. DESIGN Case report. SETTING Assisted reproduction unit of a tertiary university hospital. PATIENT(S) A 40-year-old woman with a history of primary infertility presented 10 days after oocyte retrieval because of severe abdominal pain, vomiting, and vaginal bleeding for 3 days. She had a history of mild factor VIII deficiency for 3 years. INTERVENTION(S) Evaluation of the intraabdominal hemorrhage with ultrasonography and angiography. Management of oocyte pickup complicated with intraabdominal hemorrhage. MAIN OUTCOME MEASURE(S) Treatment of massive life-threatening intraabdominal hemorrhage with bilateral uterine artery embolization. RESULT(S) After transfusion with 2 units of fresh-frozen plasma and packed red blood cell, an interventional radiologist performed percutaneous transcatheter pelvic angiography to detect abnormal vascularization and vascular blush consistent with hemorrhage and then immediate bilateral uterine artery embolization was done. The patient was discharged from the hospital 5 days later without any remarkable complications. CONCLUSION(S) Angiographic uterine artery embolization under fluoroscopic guidance is a successful nonsurgical approach for the treatment of oocyte pickup-induced life-threatening hemorrhage.

Status of vitamin D, antioxidant enzymes, and antioxidant substances in neonates with neonatal hypoxic-ischemic encephalopathy

Abstract Objective: To investigate the concentration of vitamin D (VD), glutathione peroxidase (GP), superoxide dismutase (SOD), malondialdehyde (MDA), and advanced oxidation protein products (AOPP) in neonates with hypoxic-ischemic encephalopathy (HIE). Material and methods: This study was performed prospectively in term neonates treated for HIE. Samples were collected from the neonates in study and control groups at 6–14 h and on day 5 of their lives for 25-OH vitaminD3, antioxidant enzymes including GP and SOD and oxidants substances including MDA and AOPP. Results: This study was performed with 31 term neonates with HIE and 30 healthy term neonates. Maternal VD level was statistically lower in the study group (9.8±6.8 ng/mL) than the control (16.4±8.7 ng/mL) (p = 0.002). SOD and MDA levels were significantly high, and VD level was significantly low in the study group on the first day of life (p = 0.001 and p = 0.028, respectively). SOD and GP levels were significantly high in the study group on day 5 (p < 0.05). VD was significantly low in the study group on day 5 and the proportion of subjects with VD below 5 ng/ml was significantly lower in the control group (p = <0.05). Conclusion: VD has neuroprotective and antioxidant properties. We detected VD levels were low in infants with HIE and their mothers. This finding may be useful for decreasing of brain damage.

Is the measurement of serum ischemia-modified albumin the best test to diagnose ovarian torsion?

Aim: The aim of this study is to evaluate the diagnostic value of serum oxidative stress marker levels (ischemia-modified albumin, IMA; malondialdehyde, MDA) and total oxidant status (TOS), total antioxidant status (TAS) and oxidative stress index (OSI) levels that occur in ovarian torsion and to determine the threshold value of these markers in the diagnosis of ovarian torsion. Methods: In this prospective case-control study, 34 women (the study group) with acute pelvic pain (20 with and 14 without ovarian torsion) and 40 control subjects were included. The diagnosis of ovarian torsion was confirmed with laparoscopy in all cases. Preoperative serum samples were collected in the study group. Serum oxidative stress marker levels (IMA and MDA) and TOS, TAS and OSI levels were measured. Results: Serum MDA, TOS and IMA concentrations were significantly higher in women with ovarian torsion than in the healthy control group. However, serum TAS, TOS and OSI concentrations were significantly higher in women without ovarian torsion than within the healthy control group. Only IMA significantly distinguished patients with or without ovarian torsion. The best IMA value, according to the receiver operating characteristic curve, was 0.7045 absorbance units, with 90.00% sensitivity and 92.31% specificity. The patients in the ovarian torsion group had significantly lower serum TAS and OSI levels compared with patients without ovarian torsion. Conclusion: The elevated serum IMA levels with high sensitivity-specificity values observed in women with ovarian torsion seem to have a potential role as a serum marker in the preoperative diagnosis of ovarian torsion in emergency settings.

The effect of ethinyl estradiol and drospirenone-containing oral contraceptives upon mucoprotein content of cervical mucus.

OBJECTIVE To report the effect of oral contraceptives (OC) on cervical mucoprotein content by evaluating quantitatively mucoprotein 1 (MUC1), mucoprotein 2 (MUC2), mucoprotein 5AC (MUC5AC) and mucoprotein 5B (MUC5B) levels. STUDY DESIGN This prospective controlled study included 20 women of reproductive age who had requested OC. Cervical mucus samples were obtained from the women before use of the OC and after 2 months of OC use. The mucus samples were then evaluated quantitatively for MUC1, MUC2, MUC5AC and MUC5B by ELISA by using specific antibodies. RESULTS MUC5AC mucoprotein predominated quantitatively both before and after OC use. After OC use, compared to before OC use, variable increases in the levels of all studied mucoproteins were recorded, but the increases in MUC1, MUC2 and MUC5B were statistically significant. The difference in the level of MUC2 was remarkable (+54.36 ± 31.88 ng/mL). CONCLUSION OC use may change the mucoprotein content (especially for MUC2) of cervical mucus and thus, may cause a highly viscous pattern of cervical mucus which may enhance the contraceptive efficacy of OC pills.

46,XX,der(9)t4;9)(q31.1;p24) as a novel genetic marker for spontaneous resolution of foetal pleural effusion

Primary pleural effusion is defined as the accumulation of pleural fluid and it may be isolated or can be combined with other congenital malformations such as hydrops (acid, pericardial effusion, polyhydroamnios, thickening of the placenta, skin edema). It is a rare condition, with an estimated incidence of 1:10,000–15,000 pregnancies (Longaker et al. 1989). It is usually cheilosis and this type is called ‘primary foetal pleural effusion (PPE)’ or ‘congenital chylothorax’ (May et al. 1993). PPE depends on many secondary causes such as chromosomal abnormalities, malformations and hydrops, therefore, the underlying cause determines the prognosis in developing of pleural effusion (Klam et al. 2005). Advanced isolated pleural effusion may make pressure on the vena cava and heart, this may lead to heart failure. Isolated pleural effusion should be noted as the first sign of foetal hydrops (May et al. 1993). PPE is often associated with polyhydroamnios because of compression on the oesophagus. This condition may increase the risk of preterm birth (Murayama et al. 1987). PPE is a rare condition and there is not enough information about the treatment for these rare cases, since the course may be different. Some rare cases may result in complete resolution; some may result in hydrops and death. There has been no known clinical and genetic markers for cases having the course of complete foetal pleural effusion resolution (Yinon et al. 2008). We present the case of a foetus who had a single umbilical artery with a massive bilateral pleural effusion with a novel genetic mutation (46,XX,der(9)t4;9)(q31.1;p24)) and discuss the current literature knowledge.