Fahri Burçin Fıratlıgil

Postpartum symphysis pubis separation

Sir We wish to call attention to a case of symphysis pubis separation after term vaginal birth in a 41-year-old gravida 3, with insulin-regulated gestational diabetes, who previously had two spontaneous vaginal deliveries (4000 g and 3200 g babies 16 years and 11 years ago). She delivered a 4790 g baby vaginally with McRobert’s maneuver due to shoulder dystocia, but without fetal complications. Three hours after the delivery she complained of gradually increasing severe pelvic pain and difficulty in getting up and walking. Orthopedic consultation was obtained and a pelvic X-ray showed a massive 5-cm symphyseal separation (Figure 1). There was no sign of genitourinary injury/hematoma formation. She was put on strict bed rest, mostly in the lateral decubitus position, with elastic bandages wrapped around her pelvis tightly and was given paracetamol. The control X-rays on the 2nd and 3rd days showed 3-cm and 1-cm separations, showing a surprising remission. Her pain had diminished by the second day, and she was mobilized after 72 h, to be discharged at 96 h after delivery. At a control examination 7 days later she had no pain or walking difficulties. At the 3-month examination, she had no clinical symptoms of pubic diastasis, as confirmed by the orthopedic surgeon (TE) except for a known chronic lumbar discopathy. She consented for her case to be published. The pubic symphysis has the capacity to expand to facilitate delivery – this increases the sagittal diameter of the pelvic plane under the specific hormonal action of relaxin and progesterone (1). The pubic cartilage is about 4 mm, and it may reach 10 mm during the pregnancy and delivery; 10 mm is acknowledged as the highest limit for physiological distension (2). Severe symptomatic and documented postpartum symphysis pubis separation of 5 cm is an extremely rare complication. A few wider separations have been mentioned in the literature, with healing periods of around 6 weeks, however, our case showed unusually quick remission (1). The diagnosis is mainly by radiology and anteroposterior radiography is the standard diagnostic method. The factors causing intrapartum symphysis pubis separation are not known completely. The injury mechanism involves rapid, forceful descent of the fetal head into the birth canal and wedging of the head against the anterior pelvic ring, therefore creating mechanical shear forces and ligament rupture, while hyperabduction of the thighs is also blamed (1). Except for intrapartum symphysis pubis separations, pelvic ring disruptions usually involve high-energy injuries commonly observed after traffic accidents, which are classified based on the vector of force involved and the quantification of disruption from that force, i.e. lateral compression, anteroposterior compression, vertical shear and combined mechanical injury. These are conditions that require extensive surgery (3). In our case, McRobert’s maneuver with hyperabduction for the thighs for shoulder dystocia might have facilitated the complication. In conjunction with symphysis pubis separation, complications such as bladder and urethral injury and hematoma in the space of Retzius can be observed (4). When any of these complications present, suitable alternative treatment should be planned. If separation is isolated, as in our case, a conservative approach is justified with bed rest – especially in the first days as described previously (5).

Case report of a rare dermatosis in pregnancy: Impetigo herpetiformis

Impetigo herpetiformis (IH) is a very rare type of dermatosis seen in pregnancy. According to the published work, IH during pregnancy is associated with the risk of stillbirth, and obstetric management in such cases is very important. Early recognition is important to reduce both maternal and fetal morbidity. We present a case of IH resistant to corticosteroid therapy in a 27‐year‐old pregnant woman where the pregnancy was terminated by the induction of labor.

Green serum and pregnancy: Case report

OBJECTIVES This report investigates the etiology of green serum within pregnancy. PATIENT AND METHODS A 24-year-old patient applied to our clinic for a routine control examination at her 25th week of pregnancy. In her repeated blood analysis, green serum was observed after centrifugation of the blood sample taken for an oral glucose tolerance test. After that, records of the patients blood samples collected at the 9th and 12th weeks of pregnancy to verify that these serum samples were yellow were retrospectively examined. RESULTS In the literature, no green serum case without an accompanying increase in serum ceruloplasmin level has been reported. The routine blood biochemistry of alanine transaminase: 8 U/L (10-40 U/L), aspartate amino transferase: 10 U/L (10-40 U/L), gamma glutamyl transferase: 17 U/L (7-40 U/L), indirect bilirubin 5.13 μmol/L (0.0-18 μmol/L), and total bilirubin 11.9 μmol/L (0.0-24 μmol/L). The level of serum copper detected was 0.172 μmol/L (0.14-0.173 μmol/L) and of ceruloplasmin was 600 mg/L (260-630 mg/L) within the normal reference interval. CONCLUSIONS This case proves that generation of green serum in pregnancy is not only due to an increased serum ceruloplasmin but can also be caused by other factors. Additional studies need to be performed to understand the pathophysiological mechanism and future effects of the appearance of green serum during pregnancy.

Gebelik ve tropikal parazitik enfeksiyonlar

Parazit enfeksiyonlari dunyada on milyon gebeyi etkilemektedir. Ulkemizde bolgelere gore degismekle birlikte bu oranin %20 civarinda oldugu bildirilmektedir. Son donemde ise Orta Dogu’daki catisma ortamindan kacan gocmenler ile ulkemize bu oran artis gostermektedir. Parazit enfeksiyonlari maternal, fetal ve plasental seviyede etki eder. Maternal enfeksiyon yapan parazitler Ancylostoma duodenale, Necator americanus, Ascaris lumbricoides , Echinoccoccus granulosus ; plasental enfeksiyon yapanlar Schistosoma mansoni, Schistosoma haematobium, Schistosoma japanicum , Plasmodium falciparum, Plasmodium vivax; fetal enfeksiyon yapanlar Leishmania chagasi, Leishmania donovani, Trypanosoma gambiense, Trypanosoma rhodesiense, Trypanosoma cruzi, Wuchereria bancrofti ‘dir. Tani metodlari parazit turune gore gaita, idrar, kan veya dokuda mikroskobik parazit incelemesi, serolojik test, polimeraz zincir reaksiyonudur. Bazi antihelmintik ilaclar anne sutune gecebilir. Antihelmintik ilaclarin yanisira oral demir destek tedavisi ya da cerrahi tedavi gerekebilir. Parazit enfeksiyonlarini engellemek icin insektlerden vucudu koruyucu spesifik yontemler, hijyenik besin ve su, kemoproflaksi kullanilir. Gebelikte parazit enfeksiyonlari erken tani ve uygun tedavi edilirlerse muhtemel kotu gebelik sonuclari onlenebilir

Anemia prevalence at the time of pregnancy detection

Objective: Anemia in the first trimester of pregnancy is the situation as described by the World Health Organization when the level of hemoglobin (Hb) is less than 11 g in 100 cc of blood. The prevalence of this problem is 18% in developed countries, whereas it is between 35-75% in developing countries. In this study, we aimed to determine the prevalence of anemia at the time of pregnancy detection. Materials and Methods: A retrospective cross-sectional study was designed to determine the prevalence of anemia. A total of 5228 first trimester pregnant women were admitted to the study between 2012 and 2014. Hb levels of 11 to 9.5 g/dL, 9.5 to 8 g/dL, and less than 8 g/dL were considered as mild, moderate, and severe anemia, respectively. Results: We detected mild, modarate, and severe anemia at rates of 16.64%, 3.07%, and 0.28%, respectively, in our population. The overall prevalence of anemia at the time of detection of pregnancy was 20.0%. Conclusion: Anemia is a significant risk factor for maternal mortality in developing countries. The prevalence of anemia at the time of pregnancy detection was 20% and this rate is close to those indicated in developed countries.

Cytohistological discrepancies of cervico-vaginal smears and HPV status

OBJECTIVES Discrepancies between abnormal cervical cytology or high-risk human papillomavirus (HR-HPV) status (cytolo-gy negative/HPV positive) and subsequent histological findings are a common occurrence. After using co-testing, the dis-crepancies between the HR-HPV status and cervical cytology have become an issue. In this study, we aimed to determine the characteristics of women with a discrepancy between histology and cytology/HR-HPV status, in terms of diagnosis, review and identification. MATERIAL AND METHODS A total of 52 women, patients of the University Hospital between 2013-2015, with cytohistologi-cal or HR-HPV status discrepancy were recruited for the study and retrospectively analyzed. The cytological samples were liquid-based Pap smears, classified according to the 2001 Bethesda system. The HR-HPV status was identified using the Hybrid Capture 2 HR-HPV DNA assay. The histological samples were obtained by cervical biopsy as well as large loop exci-sion of the transformation zone (LLETZ). RESULTS A cytohistological discrepancy was demonstrated in patients with (-)cytology/HR-HPV(+), ASCUS, LSIL, ASC-H, HSIL, AGC-NOS: 17.3%, 23.07%, 26.9%, 9.5%, 17.3% and 5.7%, respectively. When the degree of atypia in cytology increases, the concurrency of cervical cytology with biopsy also increases. A positive HR-HPV co-test result (19/24, 79.1%) was observed in nearly all CIN2 ≥ (+) cases. Our study emphasizes the significance of HR-HPV testing to determine CIN2 ≥ (+) cases, even in the presence of a normal cytological result. CONCLUSIONS In case of cytohistological or HR-HPV discrepancies, a careful review of the HR-HPV status and the degree of cytological atypia should be performed before further intervention.

Transobturator tape ile tedavi edilen kadın stres inkontinansın tedavisinin ameliyat sonuçları

Amac: Transobturator tape prosedurunun ameliyat sonuclari belirlemek ve bu islemin etkinligini analiz etmek. Gerec ve Yontem: Bu prospektif calismaya, stress inkontinans tanisi ile Gulhane Egitim ve Arastirma Hastanesi’nde transobturator tape ameliyati yapilan 47 kadin dahil edildi. Hasta gruplarinin, perioperatif sonuclari (ameliyat suresi, hematokrit (HTC) duzeylerindeki degisiklikler, ameliyat sonrasi komplikasyonlar, reziduel idrar hacmi degisiklikleri, hastanede kalis suresi) acisindan karsilastirildi. Bulgular: Transobturator tape operasyonu yapilan 47 hastadan, 46 (97.9%) ‘sinin mid-uretral slingleri basarili oldu. Bir (2.1%) hastanin stress inkontinansi operasyona ragmen devam etti. 47 hastadan ikisinin (4,2%) operasyon oncesi rezidu uriner volume 60 ml, digerlerinin ise 50 ml’ nin altinda idi. Operasyon sonrasi altinci haftada yapilan olcumlerde ise butun hastalarin rezidu uriner volumleri 50 ml’ nin altinda saptandi. Operasyon oncesi ve sonrasi rezidu idrar volumlerinde istatistiksel olarak anlamli farkliliklar izlendi. Calismamizda komplikasyon gozlenmedi. Sonuc: Transobturator tape; iyi sonuclari ve dusuk intra-/ post- operatif komplikasyon oranlari ile uygulanabilirligi kolay cerrahi yontemdir.

Vaginal hysterectomy with semi-full urinary bladder -

Standart vajinal histerektomi operasyonunda, vajinal bölgenin cerrahi hazırlığı sırasında mesane tümüyle boşaltılmaktadır1. Bu yaklaşımın amacı, cerrahi alanın daha met görülmesi ve cerrahi prosedürü kolaylaştırmasıdır. Vajinal histerektomide, en önemli aşama, anterior peritoneal boşluğa giriştir. Yani vezikouterin peritoneal katlantı anatomik olarak çok önemlidir. Vezikouterin boşluk ‘trianguler’ bir yapıda olup, lateral sınırlarını vezikouterin ligamentler oluşturmaktadır2. Vajinal histerektomide majör mesane yaralanması bu anatomik bölgede oluşmaktadır.Cerrahi sırasında bu anatomik seviyede, komplikasyon olasılığını minimalize edebilmek için vezikouterin sınırın net ortaya konulması çok önemlidir. Bu sınırın ortaya konulması da, mesane dokusunun anterior uterin duvardaki en alt sınırını belirlenmesiyle mümkündür. Ancak operasyon başlangıcında mesane boşaltılırsa, bu sınırı belirlemek çok güçtür.

Ovarian malignancy incidentally diagnosed during caesarean section

Overin musinoz tumorleri, seroz over tumorlerinden sonra en sik karsimizi cikan epitelyal over tumorlerindendir. Gebelik esnasinda over tumorleri ile nadir olarak karsilasmaktayiz. Olgularin bir kismi, rutin antenatal takipler sirasinda ultrasonografi ve fizik muayene ile tani alirken, diger bir kismi ise insidental olarak sezaryen sirasinda karsimiza cikmaktadir. Bu olguda, 30 yasinda nullipar hastada, sezaryen ile dogumu gerceklestirildigi esnada insidental olarak tespit edilen over tumorunden soz edilmistir.

Comparison of the Perioperative Outcomes of a Vessel Sealing Instrument-Assisted Technique with a Conventional Technique in Abdominal Myomectomy.

INTRODUCTION In gynaecologic practice, LigaSure Precise(TM) is generally used in endoscopic and open surgeries, such as hysterectomy, adnexectomy, and cancer surgery. However, there is no case report or main research article where LigaSure Precise(TM) has been used for myomectomy. We want to compare a technique using a vessel sealing instrument with a conventional technique in abdominal myomectomy. MATERIALS AND METHODS Fifty-five women who underwent abdominal myomectomy were divided two groups: (1) a vessel sealing instrument-assisted technique (24 patients); and (2) a conventional technique (31 patients) between January 2011 and December 2014 at the Department of Gynaecology and Obstetrics, Gulhane Military Medical Academy, Ankara, Turkey. The data for the operation times, the occurrence of perioperative complications, the hospitalization times, and changes in haemaglobin and haematocrit levels for the two techniques were collected and compared. RESULTS The mean operation time was 48 minutes for the vessel sealing instrument-assisted technique and 54 minutes for the conventional technique. No statistically significant differences were determined for haemoglobin and haematocrit changes, hospital stay and perioperative complications. CONCLUSION We did not find any difference in the occurrence of complications, changes in haemoglobin or haematocrit levels, or hospital stay. The vessel sealing instrument-assisted technique is feasible and effective in reducing operation times.