Mehmet Aral Atalay

Change in the ovarian environment after hysterectomy with bilateral salpingectomy: is it the technique or surgery itself?

OBJECTIVE To compare the effects of total laparoscopic hysterectomy with bilateral salpingectomy (TLH-BS) and total abdominal hysterectomy with bilateral salpingectomy (TAH-BS) on ovarian function among women of reproductive age. STUDY DESIGN One hundred and three patients with a diagnosis of benign uterine disorder were divided into two groups in this prospective longitudinal study. Patients who had never had sexual intercourse and patients with uterovaginal disproportion underwent TAH-BS (n=57), and the remaining patients (n=46) underwent TLH-BS. Ovarian function was assessed before and 6 months after surgery; ovarian volume was assessed by gray-scale ultrasonography, and levels of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2), anti-Mullerian hormone (AMH) and inhibin B were measured. RESULTS Postoperative serum FSH, LH and inhibin B decreased significantly in both groups. Postoperative serum E2 did not change significantly. Postoperative serum AMH and ovarian volume decreased significantly in the TAH-BS group (p=0.016 and p<0.001, respectively), but not in the TLH-BS group. Significant differences were observed between the TLH-BS and TAH-BS groups with respect to change in FSH (p=0.012) and ovarian volume (p=0.001); between-group differences were not significant for changes in AMH and inhibin B. CONCLUSIONS Although serum AMH did not change significantly in patients who underwent TLH-BS, ovarian aging commenced following both surgical procedures.

An unusual presentation of a submucous leiomyoma accounting to a non-puerperal uterine inversion: A case report.

Non-puerperal uterine inversion is an extremely rare gynaecological event that is usually associated with uterine tumours such as submucous or cervical leiomyomas. In this report, we describe a case of uterine inversion due to a large submucous leiomyoma in a 42-year-old multiparous and obese Caucasian woman.

Anatomic and Functional Outcomes of Paramesonephric Remnant-Supported Laparoscopic Double-Layer Peritoneal Pull-Down Vaginoplasty Technique in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: Uncu Modification

OBJECTIVE To describe modifications to the double-layer peritoneal pull-down laparoscopic vaginoplasty technique (Davydov operation) and evaluate anatomic and functional outcomes of the new technique, known as the Uncu modification. DESIGN Case series (Canadian Task Force classification III). SETTING Tertiary care university hospital. PATIENTS Women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who underwent surgery between 2010 and 2016. INTERVENTIONS Laparoscopic double-layer peritoneal pull-down vaginoplasty with paramesonephric remnant support to the neovagina. MEASUREMENTS AND MAIN RESULTS Long-term anatomic and functional satisfaction results. Twenty-seven women with MRKHS underwent surgery with the Uncu-modified Davydov procedure. At 1 year after surgery, the mean vaginal length in these patients was 7.91 ± 1.4 cm. Among the 23 patients who had regular vaginal intercourse, the mean functional satisfaction score was 8.65 ± 1.2. One patient had a perioperative bladder injury, and another patient had a rectovaginal fistula at 3 months after the operation. One woman who did not comply with the prescribed postoperative mold exercises had complete closure of the introitus. CONCLUSION The Uncu modified laparoscopic double-layer peritoneal pull-down technique appears to be an effective and safe surgical management option that is easy to learn and perform by gynecologic surgeons.

What is the optimal strategy in the management of patients with preterm premature rupture of membranes before 32 weeks of gestation

Objective: Our aim was to compare the outcomes of expectant management of pregnancy or immediate delivery in patients with preterm premature rupture of membranes (PPROM) between 24+0 and 32+0 weeks of pregnancy. Materials and Methods: This is a retrospective cohort study conducted at a tertiary medical center. Patients who were diagnosed as having PPROM between 24+0 and 32+0 weeks of gestation were selected from an electronic database. Thirty-one patients with expectant management and 22 patients with spontaneous immediate delivery were analyzed. Birth weight, Apgar score, duration of stay in the neonatal intensive care unit (NICU), composite adverse outcomes, and mortality rates of groups were compared. Binary logistic regression analysis with backward stepwise elimination was used to determine confounding factors for antenatal complications and neonatal composite adverse outcomes. Results: Gestational age at admission was smaller in the expectant management group. The median latency period was 6 days (range, 2-58 days). Although gestational age at delivery was similar, birth weights were smaller in expectant management group compared with the immediate delivery group (p=0.264 and p<0.05, respectively). Apgar scores, duration in the NICU, composite adverse outcomes, and neonatal mortality rates were similar in each group. Antenatal complication in the expectant management group was higher (p<0.05). Gestational age at delivery and serum C-reactive protein levels were two confounding factors for antenatal complication and gestational age at delivery was the only factor affecting composite adverse outcome. Conclusion: Expectant management in patients with PPROM at 24 to 32 gestational weeks might be considered as a good alternative.

Comment on "Retained Placenta Accreta Mimicking Choriocarcinoma".

We read the presented case of retained invasive placenta mimicked gestational choriocarcinoma (GCC) with an enthusiasm [1]. We thought if this is a case of GCC, which sign should be the leading sign. The clinical diagnosis of GCC is challenging in most of the cases. The predominant symptom is abnormal vaginal bleeding. Serum human chorionic gonadotropin beta (β-hCG) measurement and doppler ultrasonography examination are the leading diagnostic work-ups. Contrast-enhanced MRI is also useful for detecting an abundant blood flow in the tumor. In this case, authors did not consider to use MRI study. The authors demonstrated a serum β-hCG level of 203 IU/L, which is unlikely in cases with GCC. One should expect β-hCG measurements exceeding 100.000 IU/L in GCC [2]. This finding decrease its likelihood to be a GCC. Instead of a GCC, authors could compose their theory on the other types of gestational trophoblastic neoplasia, which are placental site trophoblastic tumor, epithelioid trophoblastic tumor, or placental site nodule. Additionally, although the authors demonstrated increased vascularity on doppler ultrasonography, the color flow pattern was seen just at the uteroplacental contiguity, not all around the mass. The presented case was a dichorionic diamniotic twin pregnancy in a nulliparous pregnant woman with 2 previous first trimester curettage operations. Authors said that the third stage of labor was complicated by retained placenta, and placentas were extracted manually and with banjo curettage under ultrasound guidance. It is possible that one of the placentas or a cotyledon was retained, was left in situ, and was not perceived during elimination process towards the placenta. In our opinion, considering the suggested findings, this case is a typical presentation of a case of morbidly adherent placenta. It would be improper to build up a theory upon findings which does not meet the GTN criteria exactly, and it would be improper to make a preliminary diagnosis of GCC in this unique case.

Meckel Gruber syndrome, A case report

ABSTRACT. Introduction: Meckel-Gruber Syndrome was first described by J R Meckel in 1822. It is an autosomal recessive disorder, and is caused by the failure of mesodermal induction. The typical triad of Meckel-Gruber Syndrome (MGS) involves meningo-encephalocele, polycystic kidneys and postaxial polydactyly. The worldwide incidence varies from 1 in 1.300 to 1 in 140.000 live births. Case: In this report, we present a case of MGS in which the diagnosis was made at 19 weeks of gestation based on ultrasonographic findings of the typical triad of the disease (encephalocele, polycystic kidneys, and polydactyly) These features were suggestive of the diagnosis of Meckel Gruber Syndrome (MGS). She had also placenta previa totalis. The patient was counselled regarding the lethal outcome of MGS. Unfortunately, the family did not approve the termination of pregnancy. At the 32nd week, she referred to hospital with complaints of vaginal bleeding and uterine contractions. An emergency cesarean section was perfomed due to plasental malposition. A 1380 gr, female fetus was delivered. First and 5th minute Apgar scores were 1 and 0, respectively. Consequently, the baby died after 45 minutes of neonatal resuscitation. Conclusıon: MGS is a lethal disorder. One cannot speak about survival of the fetus because of the pulmonary hypoplasia. The parents should be counseled about prognosis of the fetus and the outcome. Counselers should strictly give information about the recurrence risk for the next pregnancies.

Cutaneous Fistulization of an Ovarian Mature Cystic Teratoma: An Unusual Occurrence.

A bilobulated mature cystic teratoma (MCT) at the left ovary measuring 6 cm in diameter fistulized to the left lower quadrant of the anterior abdominal wall, contralateral to McBurneys point. This is the first reported case of a MCT fistulized to the skin. Symptoms, if present, usually depend on the size of the teratoma. However, most patients with a MCT are asymptomatic. Complications such as rupture of the cyst capsule are quite rare. Moreover, complication of fistulization is highly infrequent.

Intrahepatic cholestasis of pregnancy: Relationship between bile acid levels and maternal and fetal complications

Objective: Intrahepatic cholestasis of pregnancy (ICP) complicates pregnancies which is characterized by elevated serum bile acid levels. ICP increases maternal and fetal morbidities. This study was designed to determine the association of maternal and fetal complications and serum bile acid levels. Material and method: Maternal and fetal characteristics were analyzed from the medical records of 61 patients who gave birth following a pregnancy complicated with ICP between 2009 and 2013. Results: Eighty seven percent of 61 cases were singletons, and 13% of them were twins. Mean SBA level was 36 μmol/L. Preterm birth rate among singletons and twin pregnancies were 24.5% and 62.5%, respectively. Mean SBA level in preterm birth group was statistically higher with respect to the term birth group (100.8 μmol/L and 25.61 μmol/L, respectively; p=0.001). No perinatal mortality associated with ICP was detected in the study group. Conclusion: Pregnant women with the ICP compose high-risk group in regard to fetal and maternal risks. Close follow-up of these patients is required due to increased risks such as preterm delivery, meconium staining and fetal death.

Familial ectrodactyly–ectodermal dysplasia–clefting syndrome

23 cases diagnosed prenatally have been reported in the literature [2]. All of the existing ultrasound findings are associated with an increased risk of fetal chromosomal abnormalities. Furthermore, poor muscle tone, poor motor coordination, ocular abnormalities, and mental retardation have been reported in association with ACC [3]. Fetal MRI should be performed following prenatal diagnosis of fetal ACC to complement sonographic findings, and fetal karyotyping should be offered. When trisomy 8 mosaicism is detected with chorionic villi sampling or amniocentesis, the diagnosis should be confirmed by cordocentesis to avoid false-positive results [4]. Management of trisomy 8 mosaicism diagnosed prenatally is difficult and there is no current consensus. Therefore, the optimal strategy should be close follow-up and a multidisciplinary approach for fetal abnormalities. Conflict of interest