Cemal Ark

Efficacy of Intravenous Tranexamic Acid in Reducing Blood Loss after Elective Cesarean Section: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

We sought to determine the efficacy and safety of tranexamic acid (TA) in reducing blood loss during elective cesarean section (CS). We performed a randomized, double-blind, placebo-controlled study of 660 women who underwent elective CS. The patients were randomly selected to receive an intravenous infusion of either TA (1 g/10 mL in 20 mL of 5% glucose; N = 330) or 30 mL 5% glucose prior to surgery. The primary outcome was the estimated blood loss following CS. No demographic difference was observed between groups. The mean estimated blood loss was significantly lower in women treated with TA compared with women in the placebo group (499.9 ± 206.4 mL versus 600.7 ± 215.7 mL, respectively; P < 0.001), and the proportion of women in the TA group who had an estimated blood loss >1000 mL was significantly lower than in the placebo group (7 [2.1%] versus 19 [5.8%], respectively; relative risk [RR] 2.7; 95% confidence interval [CI] 1.1 to 6.3; P < 0.03). Furthermore, more women in the placebo group than in the TA group required additional uterotonic agents (48 [14.5%] versus 28 [8.5%], respectively; RR 1.7; 95% CI 1.1 to 2.6; P = 0.02). Maternal and neonatal outcomes did not differ significantly. TA significantly reduced bleeding during CS, the percentage of patients with blood loss >1000 mL, and the need for additional uterotonic agents. Furthermore, the incidence of thromboembolic events did not increase. Our results suggest that TA can be used safely and effectively to reduce CS bleeding.

Which type of mid-urethral sling procedure should be chosen for treatment of stress urinary incontinance with intrinsic sphincter deficiency? Tension-free vaginal tape or transobturator tape

Objective. To compare tension‐free vaginal tape (TVT) and transobturator tape (TOT) for surgical treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency. Design. Retrospective study. Setting. Gynecology department, Bakirkoy Women and Childrens’ Hospital, Istanbul. Sample. Three hundred women urodynamically diagnosed with stress incontinence with intrinsic sphincter deficiency underwent synthetic mid‐urethral sling procedures (TVT = 180, TOT = 120). Methods. Before the operation, a complete medical history was taken and a gynecologic examination was performed. Subjects with detrusor overactivity or previous sling surgery were excluded. Clinical checkups were conducted at 3, 6, and 12 months, and then annually. Main outcome measures. Intraoperative complications, postoperative complications, and subjective cure rates. Results. There were no significant differences in demographics between the TVT and TOT groups: mean age, parity, body mass index, menopausal status, and hormone replacement therapy. At a mean follow‐up of 31.2±9.1 (range 12–46) months, the overall cure rates were 78.3% for TVT and 52.5% TOT (p<0.0001). The risk of treatment failure in women who received TOT was 4.9 times higher than in women who underwent TVT. There were no significant differences in perioperative and postoperative complication rates between the two groups. Conclusion. TVT appears to be the preferable surgical option for the treatment of SUI with intrinsic sphincter deficiency.

Can Intravenous Injection of Tranexamic Acid Be Used in Routine Practice with Active Management of the Third Stage of Labor in Vaginal Delivery? A Randomized Controlled Study

OBJECTIVE To estimate the effects of adding intravenous tranexamic acid (TA) to the standard active management of third-stage labor to reduce vaginal blood loss during the third and fourth stages of labor. STUDY DESIGN A prospective, double-blind, equivalence randomized, controlled study was performed. Women were randomly allocated to receive an intravenous infusion of TA (experimental group, n = 228) or 5% glucose (placebo group, n = 226) at delivery of the anterior shoulder. Active management of the third stage of labor, which includes prophylactic injection of 10 IU of oxytocin within 2 minutes of birth, early clamping of the umbilical cord, and controlled cord traction following delivery, was used in both groups. The primary outcome was mean blood loss during the third and fourth stages of labor. RESULTS Mean estimated blood loss at the third and fourth stages of labor was significantly lower in the experimental group than that in the placebo group (261.5 ± 146.8 mL versus 349.98 ± 188.85 mL, respectively; p < 0.001). The frequency of postpartum hemorrhage > 500 mL was also lower in the experimental group (4, 1.8%) compared with that in the placebo controls (15, [6.8%]; relative risk, 3.76; 95% confidence interval, 1.27 to 11.15; p = 0.01). No episode of thrombosis occurred in the women who received TA. CONCLUSIONS The use of TA with standard active management of the third stage of labor reduced postpartum blood loss, and no increase in the incidence of thromboembolic events was observed.

First trimester diagnosis of sirenomelia: a case report and review of the literature

Sirenomelia sequence is a rare lethal pattern of congenital anomalies characterized by a number of hallmark skeletal anomalies, including fusion of the lower extremities or a single lower limb, bilateral renal agenesis or dysgenesis with absent or hypoplastic renal arteries, oligohydramnios, and the presence of aberrant vasculature. The etiology is still controversial. Prognosis is very poor, with the babies being stillborn or succumbing soon after birth. In the second trimester, oligohydramnios due to renal agenesis makes the diagnosis of sirenomelia difficult. Conversely, in the first trimester, the amniotic fluid volume is usually normal, unrelated to the fetal urine production. Therefore, a first-trimester or early second trimester anatomic survey of the fetus is proposed as preferable and more accurate for the diagnosis of this rare anomaly. In this article, we report a case of sirenomelia detected by two- and three-dimensional ultrasound in the 11th week of gestation and the associated literature is discussed.

Prenatal diagnosis of imperforate hymen with hydrometrocolpos

Imperforate hymen is one of the most simple and most common anomalies in the female genital organs, occurring in 0.1% of girls born at term. Some are recognized because of mucocolpos at birth, but the diagnosis is usually not detected before puberty. Rarely, obstetric sonography may prenatally detect imperforate hymen due to presentation of hydrocolpos or hydrometrocolpos in the fetus if fetal cervical and vaginal secretions accumulate in response to circulating maternal estrogens. Nonetheless, reports of prenatal ultrasound diagnosis of hydrometrocolpos are still very rare. In this article we report a prenatally diagnosed of imperforate hymen with hydrometrocolpos.

Postmenopausal tuberculosis endometritis.

Tuberculosis remains a global health problem, primarily in developing countries with inadequate health services. A significant portion of tuberculosis in these settings is extrapulmonary, including tuberculosis of the genitourinary tract. Patients with genital tuberculosis are usually young women detected during work up for infertility. After menopause, tuberculosis of the endometrium is a rare possibility probably because of the decreased vascularity of the tissues. We present a case of endometrial tuberculosis with postmenopausal vaginal bleeding.

Use of additional oxytocin to reduce blood loss at elective caesarean section: A randomised control trial

Objective:  The purpose of this prospective, randomised, double‐blind, placebo‐controlled study was to assess the effects of a 5‐IU oxytocin bolus and placebo infusion versus a 5‐IU oxytocin bolus and 30 IU infusion on the control of blood loss at elective lower segment caesarean section (C/S).

Comparison of single-dose and two-dose methotrexate protocols for the treatment of unruptured ectopic pregnancy

Summary The purpose of this study was to compare the safety and success rates of single- and two-dose methotrexate (MTX) protocols for the treatment of unruptured tubal ectopic pregnancy. This retrospective study included 87 patients with ectopic pregnancy who were treated with MTX therapy (single-dose protocol: 46 patients; two-dose protocol: 41 patients). Both protocol groups were compared with regard to success rates, β-hCG and progesterone levels, the presence of cardiac activity, a history of previous ectopic pregnancy, ectopic mass size, gestational age, adverse events, and number of repeat MTX doses. Success rates between the single-dose and two-dose methotrexate therapy groups were comparable (87% vs 90.2%; OR 0.7, 95% CI 0.18–2.75; p = 0.74). No significant differences were found between the groups in factors influencing MTX treatment success rate, including the mean β-hCG level, mean progesterone level, the presence of a positive cardiac activity, mean ectopic mass size, mean endometrial thickness, and the presence of a yolk sac. There were also no significant between-group difference were found in the percentage of women who needed a repeat dose of MTX (17.3% vs 7.3%; OR 0.3, 95% CI 0.09–1.52; p = 0.20) and in the percentage of adverse events (45.7% vs 58.7%; OR 1.6, 95% CI 0.71–3.93; p = 0.28). In conclusion, medical treatment with single-dose or with two-dose systemic MTX seem to be equal therapeutic options for patients with unruptured ectopic pregnancy.

Using intraumbilical vein injection of oxytocin in routine practice with active management of the third stage of labor: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of the routine use of intraumbilical vein injection of oxytocin with active management of the third stage of labor in reducing blood loss and length of the third stage. METHODS: In this prospective, randomized, double-blind trial, 412 women undergoing vaginal delivery who did not have risk factors for postpartum hemorrhage were randomly allocated to receive either 20 international units oxytocin diluted with 26 mL saline (n=207) or 30 mL saline (n=205) by intraumbilical vein injection. Active management of the third stage of labor (prophylactic injection of 10 international units oxytocin within 2 minutes of birth, early clamping of the umbilical cord, and controlled cord traction) was used in both groups. The primary outcome was mean blood loss during the third and fourth stages of labor. RESULTS: The mean estimated blood loss was significantly lower in women treated with oxytocin compared with women in the placebo group (195.3±81.0 mL compared with 288.3±134.1 mL, respectively; P<.001). The third stage of labor was significantly shorter in the oxytocin group than in the placebo group (4.5±1.6 minutes compared with 7.9±3.4 minutes, respectively; P<.001). The percentages of placentas remaining undelivered beyond 15 minutes were 0% in the oxytocin group and 4.4% in the placebo group (P=.002). CONCLUSION: The use of intraumbilical injection of oxytocin with the active management of the third stage of labor significantly reduced postpartum blood loss and the duration of the third stage. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01094028. LEVEL OF EVIDENCE: I

Is routine cervical dilatation necessary during elective caesarean section? A randomised controlled trial

Objective: The purpose of this prospective randomised study was to determine the effect of routine cervical dilatation during elective caesarean section on maternal morbidity.