Cem Turan

Emergency hysterectomy in modern obstetric practice Changing clinical perspective in time

OBJECTIVE Emergency hysterectomy in obstetric practice is generally performed in the setting of life-threatening hemorrhage. A retrospective review based on hospital data of 67 patients undergoing emergency peripartum hysterectomy over 10 years was undertaken. METHODS Comparison of two different time periods regarding the incidence and the indications of obstetric hysterectomies was made. RESULTS The number of patients with hysterectomy in the first 5 years of the study period (1985-1989) was 43 and during the last 5 years (1990-1994) it was 24. The incidence of hysterectomy during 1985-1989 was 1 in 2495 deliveries and the most common indication for hysterectomy was uterine atony (42%) followed by placenta accreta (25.5%) and uterine rupture (21%). On the other hand, the incidence of hysterectomy during 1990-1994 was 1 in 4228 deliveries and the ranking of indications of hysterectomy was slightly different from group 1 as mostly placenta accreta (41.7%) followed by uterine atony (29.2%). The maternal mortality rate was 4.5% in this series. CONCLUSION This study showed that over the last decade the incidence of emergency hysterectomy in obstetric practice has declined in our clinic due to availability of high standard obstetric care and more liberal use of cesarean section at risk deliveries, better controlled use of oxytocin and internal iliac artery ligation.

Endometriosis in association with müllerian anomalies.

There have been many theories proposed regarding etiology and pathogenesis of endometriosis. The theories of retrograde menstruation, celomic metaplasia, and müllerian remnants are among these. In order to find out whether a higher prevalence exists in patients with müllerian anomalies and to test these theories, we reviewed the case records of our reproductive endocrinology clinic set up between 1989 and 1994. The study group included patients with müllerian anomalies (n =186) whereas the control group consisted of patients without müllerian anomalies (n = 3,240). The frequency of endometriosis was 37 of 186 (19.8%) in the study group as compared with 619 of 3,240 (19.1%) in the controls (p > 0.05). In 1 patient without functioning endometrium endometriosis was demonstrated. Obstructive anomalies were associated more with endometriosis as compared with nonobstructive anomalies (p < 0.001). The nonobstructive anomalies did not present a higher prevalence as compared with controls (p > 0.05). These results show that endometriosis is not more frequent in patients with müllerian anomalies as a whole, but outflow obstruction is an important contributing factor. Evaluating patients with müllerian anomalies contributes proof in favor of the theories of retrograde menstruation and celomic metaplasia, but against a possible relation of a developmental defect of differentiation or migration of the müllerian duct system during embryogenesis.

Chronic inflammation and elevated homocysteine levels are associated with increased body mass index in women with polycystic ovary syndrome

Background. Women with polycystic ovary syndrome (PCOS) are insulin-resistant and have increased risk for type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). But it is controversial whether the increased risk of CHD and T2DM is associated with endocrine abnormalities occurring as a consequence of PCOS or whether it is related to obesity or metabolic changes frequently seen in women with PCOS. Objective. Since both homocysteine (Hcy) and C-reactive protein (CRP) are supposed to predict T2DM and CHD, we investigated their possible relationship with insulin resistance, obesity, hyperandrogenemia and metabolic alterations in 44 PCOS women and 26 healthy controls matched by age and body mass index (BMI). Results. Hcy and CRP levels were significantly elevated in PCOS women compared with controls (13.30 ± 4.81 vs. 9.02 ± 3.36 μmol/l, p < 0.05 and 4.22 ± 2.95 vs. 2.66 ± 2.49 mg/l, p < 0.05). There was no correlation between Hcy and CRP (r = 0.171, p = 0.05) as two risk markers. While plasma Hcy levels were correlated with BMI, ratio of luteinizing hormone (LH) to follicle-stimulating hormone (FSH), total testosterone, free testosterone, triglyceride and insulin levels and homeostatic model assessment–insulin resistance index (HOMA-IR) (p < 0.05), CRP was correlated with BMI, total cholesterol, triglyceride, low-density lipoprotein cholesterol and insulin levels and HOMA-IR (p < 0.05). There was no correlation of CRP with parameters of PCOS such as testosterone and LH/FSH ratio (p > 0.05). Multiple regression analysis revealed BMI as the major factor examined that influenced both Hcy and CRP levels. Conclusions. In PCOS women, plasma levels of Hcy and CRP were significantly elevated compared with age- and BMI-matched controls. Although most of the PCOS-related endocrine and metabolic changes are related to elevated plasma Hcy and CRP levels in PCOS women, BMI seems to be the major factor determining CHD and T2DM in women with PCOS.

Diagnosis of premature rupture of membranes by identification of β-HCG in vaginal washing fluid

OBJECTIVE To evaluate the reliability of vaginal washing fluid beta-HCG for the diagnosis of premature rupture of membranes (PROMs) and to determine a cut-off value. STUDY DESIGN A total of 141 pregnant women were recruited. The first group consisted of 73 pregnant women between 14 and 41 weeks of gestation with the complaint of vaginal fluid leakage. These were further subdivided into two subgroups. Group 1-confirmed PROM group (amniotic fluid pooling (+) and nitrazine paper test (+); 34 patients). Group 2-suspected but unconfirmed PROM group (amniotic fluid pooling (+/-) and/or nitrazine paper test (+/-); 39 patients). The control group (Group 3) consisted of 68 pregnant women between 14 and 41 weeks of gestation without any complaint or complication. All patients underwent speculum examination for amniotic fluid pooling, nitrazine paper test, vaginal washing fluid beta-HCG sampling and ultrasonographic examination for gestational age determination, amniotic fluid index calculation. One-way ANOVA test, Scheffe multiple comparison test and receiver operating characteristic (ROC) curve analysis were used. RESULTS Geometric mean values of beta-HCG was found to be 95 for Group 1, 14 for Group 2, 10 for Group 3 (P<0.0001). The optimal cut-off was a beta-HCG value of 65 mIU/ml (sensitivity 68%, specificity 95%, positive predictive value 82%, negative predictive value 90%, accuracy 87%). CONCLUSION Vaginal washing fluid beta-HCG determination for the diagnosis of PROM is reliable, simple and rapid test.

Comment on: The effect of uterine fundal pressure on the duration of the second stage of labor: A randomized controlled trial

Objective. To determine the effect of uterine fundal pressure on shortening the second stage of labor and on the fetal outcome. Design. Randomized controlled trial. Setting. Teaching and research hospital. Sample. One hundred ninety‐seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. Methods. Random allocation into groups with or without manual fundal pressure during the second stage of labor. Main outcome measures. The primary outcome measure was the duration of the second stage of labor. Secondary outcome measures were umbilical artery pH, HCO3−, base excess, pO2, pCO2 values and the rate of instrumental delivery, severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. Results. There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures except for mean pO2 which was lower and mean pCO2 which was higher in the fundal pressure group. Nevertheless, the values still remained within normal ranges and there were no neonates with an Apgar score <7 in either of the groups. Conclusion. Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.

Diagnostic power of the vaginal washing-fluid prolactin assay as an alternative method for the diagnosis of premature rupture of membranes

Objective: The purpose of this study was to determine the reliability of the vaginal washing-fluid prolactin assay for the diagnosis of premature rupture of membranes (PROM) and to determine a diagnostic cut-off value.Study design: Seventy pregnant women between 11 and 40 weeks of gestation who were admitted with vaginal fluid leakage were included in the study group, and were then further subdivided into two subgroups according to amniotic fluid pooling and nitrazine paper test results. Group 1 was the ‘confirmed PROM group’, positive for both pooling and nitrazine (38 patients). Group 2 was the ‘suspected but unconfirmed PROM group’ which had possible pooling and/or nitrazine (32 patients). Seventy pregnant women between 11 and 40 weeks of gestation without any complaint and complication were included in the control group (group 3). All patients underwent vaginal washing-fluid sampling and prolactin level determination. For the statistical analysis one-way analysis of variance, Tukey multiple comparison test, χ2test and receiver operating characteristic (ROC) curve analysis were used.Results: Geometric mean values of vaginal washing-fluid prolactin levels were 616.59 µIU/ml for group 1, 23.98 µIU/ml for group 2 and 10 µIU/ml for group 3 (p<0.0001). The optimal diagnostic cut-off value was found to be 30 µIU/ml with 95% sensitivity, 78% specificity, 84% positive predictive value, 93% negative predictive value, 87% accuracy and 11.30 relative risk.Conclusions: We recommend vaginal washing-fluid prolactin level determination as an alternative diagnostic method for PROM.

Vulvar syringoma exacerbated during pregnancy

Although syringoma of the eyelids and the cheeks are well known and defined, vulvar syringoma is a rare clinical variant of this benign eccrine tumor. A case of syringoma of the vulva exacerbated during pregnancies with regression in the periods in between is presented. Histopathological examination showed typical features of syringomas. Only 20 patients with vulvar syringoma have been previously reported in the literature.

Evaluation of the effects of various gestagens on insulin sensitivity, using homeostatic model assessment, in postmenopausal women on hormone replacement therapy

The objective of the present study was to compare the effects of various gestagens on insulin sensitivity in postmenopausal women on hormone replacement therapy (HRT). This prospective study enrolled 156 postmenopausal women who had menopausal status for at least 6 months. Group 1 was treated with 17β-estradiol (E2; 2 mg) plus norethisterone acetate (NETA; 1 mg); Group 2 was given E2 (2 mg) plus medroxyprogesterone acetate (MPA; 2.5 mg); Group 3 was given E2 (2 mg) plus dydrogesterone (DG; 10 mg); and Group 4 was given E2 (2 mg) plus micronized progesterone (MP; 100 mg). Group 5 was the surgical menopausal group and was given only E2 (2 mg) continuously. All 156 subjects completed the 3-month follow-up on the trial. The patients were analyzed by using homeostatic model assessment (HOMA) for insulin sensitivity before treatment and 3 months after treatment, comparing the effects of various HRT regimens on insulin sensitivity. No significant differences were found in the baseline characteristics of the patients (p > 0.05). There were no significant differences in mean values of HOMA before HRT among the five groups (p > 0.05). There were statistically significant differences in mean values of HOMA only in Group 1 (E2 + NETA) and Group 3 (E2 + DG) after HRT (p > 0.05). E2 + NETA and E2 + DG were found to improve insulin sensitivity in postmenopausal women after 3 months of treatment, whereas E2 + MPA, E2 + MP and E2 only did not show such an effect in postmenopausal women.

Transvaginal sonographic findings of chronic ectopic pregnancy

Chronic ectopic pregnancy is not precisely defined in gynecologic and sonographic texts. The diagnosis of this enigmatic clinical condition is frequently not made until laparotomy. In the present retrospective study, we evaluated the transvaginal sonographic findings of cases who were diagnosed as chronic ectopic pregnancy intraoperatively and/or postoperatively. The incidence of chronic ectopic pregnancy was found to be 20.3% (62/305) of all ectopic pregnancies. Of these 62 cases, 55 had transvaginal sonographic examination. On transvaginal sonographic examination, all 55 cases of chronic ectopic pregnancy had a complex adnexal mass with an empty uterus and only 18 (32.7%) had simple fluid in the pelvis/cul-de-sac. In the majority of cases (82.7%, n = 48), there was a non-homogeneous echo pattern within the adnexal mass. Of 55 cases, 30 had color Doppler flow examination, of whom none had color Doppler flow imaging on the wall of the mass or within the mass. There was a negative quantitative beta human chorionic gonadotropin (beta-hCG) assay (i.e. 0 mIU/ml) in only 4 cases. Based on this study, we concluded that chronic ectopic pregnancy is not a rare clinical entity and should be considered in differential diagnosis among patients presenting with an adnexal mass and an overt clinical picture. Transvaginal sonography is sensitive in diagnosing chronic ectopic pregnancy, but not specific. The combined use of transvaginal ultrasonography and beta-hCG assay increases diagnostic accuracy. However, it should be kept in mind that a negative beta-hCG value does not rule out chronic ectopic pregnancy.

Ritodrine Tocolysis and Neonatal Intraventricular-Periventricular Hemorrhage

Betamimetic drugs are commonly used for tocolytic therapy. To determine their potential role in periventricular-intraventricular neonatal hemorrhage (IVH), 103 preterm births with cranial ultrasonography results were evaluated for the history of betamimetic therapy. The study group was divided into three subgroups according to the cause of the preterm delivery: 44 patients were accepted as tocolysis failure (group A); 53 patients were too late for tocolysis (group B), and these latter cases were taken as controls for group A; for the remaining 6 patients, tocolysis was contraindicated due to fetomaternal reasons (group C), and these cases were not included in the analysis. In group A, 32 patients got ritodrine, 6 patients got combined therapy including ritodrine plus magnesium sulfate or nifedipine. When cases in group A who got ritodrine only or combined therapy are compared with the no-treatment group, no significant difference in neonatal IVH incidences could be found (p > 0.005). Ritodrine does not appear to affect the incidence of neonatal IVH.