Ibrahim Polat

Perinatal outcomes in severe preeclampsia-eclampsia with and without HELLP syndrome.

Objective: Our purpose was to find out and compare perinatal outcomes in pregnancies complicated by severe preeclampsia-eclampsia with and without HELLP syndrome. Methods: Clinical and laboratory findings, and perinatal-neonatal outcomes of all pregnants with severe preeclampsia, eclampsia and HELLP have been prospectively recorded. Results were compared by means of Student’s t test, χ2 analysis and Fisher’s exact test as appropriate. Results: Among 367 consecutive severe preeclampsia, 106 (29%) had HELLP syndrome, 261 (71%) had severe preeclampsia and eclampsia. Mean gestational age and birth weight at delivery in severe preeclampsia without HELLP syndrome and in HELLP syndrome were 34.1 ± 6.1 vs. 33.0 ± 5.8 weeks (p = 0.119) and 1,886 ± 764 vs. 1,724 ± 776 g (p = 0.063), respectively. Comparing overall fetal mortality (4.6 vs. 10.3%, p = 0.009) and perinatal mortality (8.0% vs. 16.8%, p = 0.026) in severe preeclampsia-eclampsia and HELLP syndrome, respectively, there were statistically significant differences. But when analyses were performed according to gestational age before and after 32nd gestational week, the difference of perinatal mortality between the two groups was non-significant (p = 0.644 and p = 0.250), suggesting borderline difference. The most common contributing factor for fetal death after 32nd week was due to abruptio placenta without prenatal follow-up. Neonatal morbidity and neonatal mortality (4.8 vs. 6.3%, p = 0.905) in severe preeclampsia-eclampsia and HELLP syndrome respectively were similar and the difference was statistically nonsignificant. Conclusions: Perinatal mortality and neonatal morbidity-mortality according to gestational age before and after the 32nd week were similar in HELLP syndrome compared with severe preeclampsia-eclampsia without HELLP but overall fetal mortality was higher in HELLP syndrome with no regular prenatal care.

Perinatal Outcomes of Twin Pregnancies Discordant for Major Fetal Anomalies

Objective: The aim of this study was to determine perinatal outcomes of twin pregnancies discordant for a major fetal anomaly and to compare with twins without anomaly. Methods: All twin pregnancies admitted or referred to the maternal-fetal unit were prospectively entered into a computer database. Chorionicity, fetal anomaly, mean gestational age at delivery, birth weight and perinatal survival rate were reviewed. Main Outcome Measures: Mean gestational age at delivery, birth weight and perinatal survival rate of twins with and without anomaly. Results: There were 48 cases of monochorionic diamniotic (MCDA), 2 cases of monochorionic monoamniotic (MCMA) and 217 twins with dichorionic (DC) placentation. Out of 267 twin pregnancies, there were 17 (6.3%) twins with fetal anomaly. Twins discordant for a major fetal anomaly were diagnosed in 13 cases (4.8%). We observed 3 cases with MCDA and 10 cases with DC placentation and the incidence of discordance for a major fetal anomaly as 4.6% (10/217) in DC and 6.0% (3/50) in MC twin pregnancies. We identified 8 cases (62%) with craniospinal, 2 (15%) with gastrointestinal, 2 (15%) with urinary system, and 1 case (8%) with both craniospinal and gastrointestinal anomalies. There were significant differences between the normal co-twin of the major anomaly group (n = 13) and twins without anomaly group (n = 235) in mean gestational age at delivery (32 vs. 34 weeks; p = 0.029), mean birth weight (1,640 vs. 2,030 g; p = 0.022) and perinatal survival rate (69.2 vs. 91.1%; p = 0.018), respectively. Conclusion: The presence of a fetus with a major anomaly in a twin gestation increases the risk of preterm delivery, low birth weight and perinatal mortality of the normal co-twin.

Maternal and Fetal Outcomes in HELLP Syndrome Complicated with Acute Renal Failure

Objective. This study reviews maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure (ARF), and compares clinical and laboratory findings of the cases of HELLP syndrome that did not develop ARF. Materials and Methods. All pregnant women with hypertensive disorders admitted or referred to the maternal and fetal unit were recorded into a perinatal database between January 15, 2002 and September 15, 2003. During the study period, out of 615 cases of hypertensive pregnancy, we followed and delivered 347 cases of severe preeclampsia, of them 132 cases were diagnosed as HELLP syndrome. ARF was defined as creatinine level ≥ 1.2 mg/dL and/or oliguria < 400 mL/24 hr. The cases were divided into three groups on the basis of the highest creatinine level recorded during hospitalization: creatinine < 1.2 mg/dL, creatinine ≥ 1.2 to 2.0 mg/dL, and creatinine ≥ 2.0 mg/dL. Statistical comparisons were performed by Student t test, X2 analysis, and Fishers Exact test as appropriate. The value of P < 0.05 was considered significant. Results. ARF developed in 8.9% (n:31) of severe preeclampsia (n:347); of them, 15 (4.3%) cases were nonoliguric, and all had mildly elevated creatinine levels between 1.2 and 1.9 mg/dL. Moderately elevated creatinine levels were 2 to 3.9 mg/dL in 10 cases, and severely elevated creatinine levels were 4 to 8.4 mg/dL in 6 cases, for a total of 16 (4.6%) cases; creatinine levels were ≥ 2.0 mg/dL (range: 2.0–8.4 mg/dL). HELLP syndrome was the most frequent cause of ARF, 64.5% (n:20/31), and was observed in 15% (n:20) of 132 cases of HELLP syndrome. Fourteen (88%) of 16 cases that had oliguria and creatinine levels ≥ 2 mg/dL were detected in HELLP syndrome (n:14/132; 10.6%). Major maternal complications in HELLP syndrome with ARF and creatinine level ≥ 2 mg/dL in the study group were abruptio placentae (42.8%; n:6/14), incisional hematoma (21%; n:3/14), pulmonary edema (14%; n:2/14), cesarean hysterectomy (7%; n:1/14), and dialysis (50%; n:7/14). There was no maternal mortality. All patients complicated with ARF were discharged without renal impairment. Perinatal mortality was 26.1% in the cases of HELLP syndrome with ARF‐creatinine ≥ 1.2 mg/dL and further increased to 37.5% when creatinine levels were above 2.0 mg/dL, compared with 11.8% in the cases having creatinine < 2.0 mg/dL, and the difference was statistically significant (p:.007). Conclusions. The most contributing factors leading to ARF in HELLP syndrome were abruptio placentae and HELLP syndrome complicated with ARF, particularly, oliguric ARF has relatively higher maternal complications and perinatal mortality.

Natural History of 11 Cases of Twin-twin Transfusion Syndrome Without Intervention

The natural history of 11 cases of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancies has been reviewed. Seven cases before 28 weeks and four pregnancies after 28 weeks had been followed up without intervention. Eight cases had premature uterine contractions. All seven pregnancies before 28 weeks aborted, leading to a 100% mortality rate. After 28 weeks all mothers delivered live births. The diagnosis of TTTS before 28 weeks, and with premature uterine contraction, seems to be a poor prognostic sign.

The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation.

A retrospective study involving 972 twin births was conducted to evaluate the maternal and fetal outcomes of twin pregnancies complicated by single fetal death. The incidence of single fetal death in twin pregnancies after 20 weeks was 3.3%. Preterm birth rates for 37 and 32 gestational weeks were 81.3% and 41.6% respectively. The median interval between the diagnosis of fetal death and the delivery was 11 days (range 1-27 days). Eighteen (56%) infants were delivered by cesarean and 14 (43%) vaginally. Twin-twin transfusion syndrome (TTTS) was the cause of single fetal death in 8 of 32 twin pregnancies (25%). Ten of the surviving co-twins were lost in the neonatal period (31.3%) and half of those neonatal deaths were due to TTTS. TTTS is the major contributor for perinatal mortality in same-sex twins complicated by single fetal death. The death of one twin in utero should not be the only indication for preterm delivery, and in case of severe prematurity with a stable intrauterine environment; expectant management may be advisable until fetal lung maturation ensues.

Subfoveal Choroidal Thickness in Preeclampsia: Comparison with Normal Pregnant and Nonpregnant Women

ABSTRACT Purpose: To compare the subfoveal choroidal thickness (SFCT) in preeclampsia, normal pregnancy, and non-pregnant women using enhanced depth imaging optical coherence tomography (EDI-OCT). Methods: One hundred nineteen volunteers were enrolled in this prospective and comparative study. The participants were divided into three groups: group 1 (33 preeclamptic women), group 2 (46 normal pregnant), and group 3 (40 non-pregnant healthy women). The SFCT was measured by EDI-OCT. The refractive error, intraocular pressure (IOP), axial length (AL), central corneal thickness (CCT), systolic and diastolic blood pressure, and ocular perfusion pressure (OPP) were also measured. Medical records of pregnant women, including gestational age, maternal weight gain, weight, and proteinuria, were noted. Results: Mean SFCT of groups 1, 2, and 3 were 333.8 ± 55.3 μm (range 235-440 μm), 368.6 ± 67.6 μm (range 223-517 μm), and 334.8 ± 59.9 μm (range 197-432 μm), respectively. The mean SFCT was thicker in group 2 than that in groups 1 and 3 (p = 0.045 and p = 0.038, respectively), whereas no significant difference was seen between groups 1 and 3 (p = 1.0). In group 1, SFCT showed a negative correlation with the CCT (p = 0.009, r = -0.493). In group 2, SFCT showed a positive correlation with OPP (p = 0.030, r = 0.321) and a negative correlation with gestational age and fetal weight (p = 0.008, r = -0.387 and p = 0.011, r = -0.373, respectively). Conclusion: Our results suggested that SFCT was significantly thicker in normal pregnant women than non-pregnant women. However, SFCT values of preeclamptic women were similar to those of non-pregnant women.

Peripartum hysterectomy in Turkey: A case-control study

Summary This was a retrospective review of all cases of peripartum obstetric hysterectomy performed at the Istanbul Bakirkoy Women and Childrens Teaching Hospital in the period between January 2001 and September 2008. We included any women who required emergency hysterectomy to control major postpartum haemorrhage after delivery. During the study period, there were 91 cases of peripartum hysterectomy. Two controls per case were randomly selected from the remaining births by using the random table. The incidence of emergency peripartum hysterectomy was 0.67 in 1,000 deliveries. The main indication for emergency hysterectomy was uterine atony in 52 cases (57.1%). The most independent risk factors for emergency hysterectomy were multiparity (odds ratios (OR) 17.3, 95% confidence interval (95% CI) 8.7–34.6); caesarean delivery in index delivery (OR 6.7, 95% CI 3.8–11.9) and caesarean section for placental abruption (OR 3.8, 95% CI 0.4–33.4). Our study suggests that multiparity, primary or repeat caesarean deliveries for placental abruption are independently associated risks for peripartum hysterectomy and uterine atony is the still most common indication for peripartum hysterectomy in Turkey.

Suction curettage as first line treatment in cases with cesarean scar pregnancy: feasibility and effectiveness in early pregnancy

Abstract Objective: A cesarean scar pregnancy (CSP) is an extremely rare form of an ectopic pregnancy, which is defined as the localization of a fertilized ovum surrounded by uterine muscular fiber and scar tissue. The objective of this study was to discuss the management options for CSPs in a singleton center. In the current study, we discussed the current management options for CSPs based on our 6 years of experience. Material and methods: A retrospective evaluation of diagnosed and treated 26 patients with CSPs in Istanbul Kanuni Sultan Suleyman Training and Research Hospital during a 6-year period was discussed. Suction curettage was performed as first-line treatment in patients with a gestation <8 weeks and myometrial thickness >2 mm. Results: Twenty-two (84.6%) patients with CSPs were initially treated surgically (curettage and hysterotomy) and four (15.4%) patients were treated medically with methotrexate injections. Vacuum aspiration was performed in 19 patients as a first-line treatment, six of them needed an additional Foley balloon catheter to be inserted for tamponade because of persistent vaginal bleeding. Suction curettage was successful in 12 patients. The treatment rate for suction curettage with or without Foley balloon catheter tamponade was 16 of 19 (84.2%). Conclusion: The early diagnosis of a CSP (7–8 weeks gestation) with a β-hCG level <17.000 mIU/ml and a myometrial thickness >2 mm can be treated with suction curettage with or without placement of a uterine Foley balloon as curative treatment.

Osseous metaplasia of the cervix and endometrium: a case of secondary infertility

OBJECTIVE To report a case of osseous metaplasia of the cervix and endometrium as a cause of secondary infertility. DESIGN Case report. SETTING Istanbul Bakirkoy Women and Children Teaching and Research Hospital. PATIENT(S) A 31-year-old patient with secondary infertility owing to osseous metaplasia of the endometrium and cervix in whom uterine perforation occurred during the removal of bone fragments. INTERVENTION(S) Diagnostic and operative hysteroscopy and laparotomy. MAIN OUTCOME MEASURE(S) Visualization of the disappearance of the osseous metaplasia region with transvaginal ultrasound examination after the hysteroscopy intervention. RESULT(S) Osseous metaplasia lesions are removed by operative hysteroscopy. During this operation, laparotomy was done because of perforation of the uterine wall, and the perforated area was repaired. Two weeks after surgery, the patient underwent a transvaginal ultrasound examination, and the abnormal ultrasound appearance had resolved. CONCLUSION(S) As a rare cause of infertility, osseous metaplasia can be seen in the cervix and the endometrium. If osseous metaplasia is deep enough during operative hysteroscopy, uterine perforation may occur. Clinicians must be careful for this reason, especially in cases of deep osseous metaplasia.

Double notches: association of uterine artery notch forms with pregnancy outcome and severity of preeclampsia

Objective: To assess uterine artery Doppler waveforms and notches performed in the third trimester as a predictor of adverse outcomes. Methods: Of 490 preeclampsia (PE) patients between 24 and 34 weeks gestation, 166 were diagnosed with mild PE and 324 were diagnosed with severe PE. Patients were divided into four groups (no notch, a unilateral notch, bilateral notches and double notches). Results: Bilateral and double notches were predictive of shorter follow-up times, adverse laboratory outcomes, HELLP syndrome, prematurity, neonatal intensive care unit admission and perinatal mortality. Conclusion: Double notches represent progressive deterioration in the uterine artery and are predictive of adverse maternal outcomes.