Mehmet Özgür Akkurt

Can we consider cesarean myomectomy as a safe procedure without long-term outcome?

Abstract Aim: To investigate short- and long-term outcomes in women undergoing cesarean myomectomy (CM). Methods: This was a retrospective study that explored short-term outcomes of women, who underwent cesarean operations with or without myomectomies (CM controls) in a single tertiary center throughout a 6-year-period. For long-term outcomes, the mean duration of follow-up was 6.3 ± 1.0 years. Results: There were no differences among the CM (n= 91) and control groups (n = 60) considering mean change in hemoglobin and hematocrit levels, hemorrhage, as well as requirement for blood transfusions with a slightly increased operative time. Multiple myomas, and cervical and cornual localization were associated with an increased drop of hemoglobin and hematocrit (p < 0.05). Subsequent pregnancy and recurrence rates were 35% (32/91) and 5.5% (5/91), respectively. Preterm delivery (n = 1, 3.1%), uterine dehiscence (n = 1, 3.1%), placenta previa (n = 1, 3.1%) and mild-to-severe post-CM adhesions (n = 8, 25%) were observed in subsequent pregnancies. Recurrence was identified in five of the nonpregnant (5.5%) women, and three of these (4.1%) underwent an additional major surgery. There was no recurrence in subsequent pregnancies. Conclusion: The recurrence of myoma was relatively low following CM. Subsequent pregnancy is protective for recurrence of myoma without increased adhesion formation and obstetric complications.

The evaluation of risk factors for failed response to conservative treatment in tubo-ovarian abscesses.

OBJECTIVE The aim of our study is to assess the risk factors for medical treatment failure and to predict the patients who will require the surgical therapy as well as to predict the factors affecting treatment success. MATERIAL AND METHODS This was a cross-sectional study including 76 women with tubo-ovarian abscesses (TOA) who were either conservatively or surgically treated and were admitted to two gynecology units over a 4-year period. The demographic characteristics of the patients, gynecologic and obstetric histories, size and localization of abscesses were recorded. Gentamicin plus clindamycin treatment protocol was implemented for all patients. Ampicillin treatment was added in three patients with the positive culture of Actinomyces. Response to treatment was evaluated after 48-72 h. Patients who fail to respond to medical treatment required surgery or percutaneous drainage. We compared clinical and laboratory factors between the groups. RESULTS In surgery group, patients were significantly older than the others (44.9±5.4 versus 39.1±7.6 years). Fifty-six patients (74%) responded to antibiotics and 20 of the patients required surgical intervention. Patients treated with antibiotics were hospitalized for an average of 6.32±2.8 days versus 12.75±5.6 days for those who required surgery (p=0.021). Patients who were surgically treated had a mean size of TOA of 67.9±11.2 mm versus 53.6±9.4 mm for those treated with antibiotics alone (p=0.036). There were no significant differences between groups in laboratory parameters, except for initial white blood cell (WBC) counts. The complications of surgery included in descending order of frequency blood transfusions, surgical wound infections, bowel injury, and bladder injury. CONCLUSION An increased size of pelvic mass, higher initial WBC counts, advanced age, and smoking were all associated with failed response to conservative treatment. It is important to identify the risk factors to distinguish patients who will respond to antibiotic therapy and those who will need a surgical treatment. Thus, the required early intervention can result in a reduction in the morbidity associated with TOA.

Utero-cutaneous Fistula after Multiple Abdominal Myomectomies: A Case Report

BACKGROUND Utero-cutaneous fistula (UCF) is an extremely rare entity and only a few case reports have been published. Most UCFs develop secondary to post-partum or postoperative complications. CASE REPORT A 42 year-old woman began to complain from bleeding and malodorous discharge through her abdominal incision scar. The fistula tract with a thickness of 8 mm was observed between the uterus and wound using magnetic resonance imaging (MRI). The risks and benefits of conservative treatment have been discussed; the patient demanded definitive treatment, so hysterectomy and excision of the fistulous tract was performed. Histopathology of the fistulous tract showed endometrial epithelization of the tract lined by granulation. CONCLUSION There are many causes of such an extremely rare entity. Patients should be counseled for medical or surgical treatment considering their age, accompanied uterine pathologies such as fibroids and fertility expectations.

Reliability of posterior-left atrium space index measurements during 20–24 weeks of gestation in structurally normal fetuses

Abstract Objective: We aimed to evaluate the correlation between clinical parameters and the post-left atrium (LA) space index, which is a candidate screening marker for total anomalous pulmonary venous connection (TAPVC). We also calculated the inter- and intra-observer variabilities of measurements for this parameter. Methods: The LA-descending aorta distance/descending aorta diameter ratios (post-LA space index) were obtained from 165 fetuses between 20 and 24 weeks of gestation. Regression analyses were utilized to evaluate the correlations across clinical parameters and the post-LA space index. Intraclass correlations coefficients were calculated for the intra- and inter-observer agreements of three examiners with different sonographic experience. Results: The mean (±SD) maternal and gestational age (GA) was 28.6±4.9 years and 21.7±0.9 weeks of gestation, respectively. In multivariate analyses, there was no correlation between post-LA space index and maternal age, fetal gender, or GA at cardiac scan. There were moderate to strong correlations across the measurements by different examiners, indicating good inter- and intra-observer agreements. Conclusion: The post-LA space index during 20–24 weeks of gestation is a simple and reliable marker that is not affected by GA. However, its potential as a screening tool for TAPVC warrants further clinical investigation.

Maternal and perinatal outcomes in pregnancies with multiple sclerosis: a case-control study.

Abstract Objective: To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center. Methods: We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ2 tests. Logistic regression models were constructed to determine independent effects. Results: Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models. Conclusion: MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

Maternal serum ferritin as a clinical tool at 34-36 weeks' gestation for distinguishing subgroups of fetal growth restriction.

Abstract Objective: To compare maternal ferritin levels across pregnancies with fetal growth restriction including SGA and IUGR compared to appropriate for gestational age (AGA). Methods: Three groups were enrolled: AGA, SGA (birth weight below 10th percentile for gestational age with no placental insufficiency findings), and IUGR (birth weight below 5th percentile for gestational age accompanied by abnormal umbilical artery Doppler waveforms and/or oligohydramnios). Maternal serum ferritin samples were obtained at gestational weeks 34 through 36, and delivery occurred at or beyond 36 weeks. Results: A total of 126 pregnancies with AGA (36%), SGA (40%), and IUGR (24%) were enrolled. The mean maternal serum ferritin level was higher in the IUGR group than in the AGA group (59 μg/l versus 32.5 μg/l, p < 0.001). A maternal serum ferritin cutoff of 48 μg/l was found to be optimal for distinguishing between IUGR and AGA with a sensitivity of 67.7%, specificity of 92%, PPV of 84%, NPV of 82%, diagnostic accuracy of 82.7%, LR + of 8 and LR- of 0.3, respectively. Conclusion: Maternal serum ferritin levels differ in pregnancies with IUGR. The role of maternal serum ferritin measurements as a clinical tool for distinguishing different forms of fetal growth restriction warrants further investigation.

An unusual complication of vesicoamniotic shunt: coiling of the shunt around lower extremity associated with dislodgement

Introduction Posterior urethral valve (PUV) is the most common aetiology of foetal obstructive uropathy with an incidence of around 1/5000 to 1/8000 pregnancies (Brown et al. 1987). Untreated PUV is associated with increased neonatal morbidity and mortality due to renal dysplasia and pulmonary hypoplasia (Freedman et al. 2000). Vesicoamniotic shunting (VAS) is a procedure that aims to reduce intraluminal pressure of the foetal bladder with subsequent involvement of the upper urinary tract and prevent pulmonary hypoplasia due to secondary oligohydramnios. In previous reports, iatrogenic anterior wall defects secondary to placement of shunts has been reported (Gehring et al. 2000; Irwin & Vane 2000). Here, we report an unusual complication of VAS, coiling of the shunt around foetal lower extremity associated with dislodgement.

Relationship between endometrial thickness and neutrophil/lymphocyte ratio with endometrial malignancy in 386 postmenopausal uterine bleeding cases

Introduction: In our study, endometrial thickness with neutrophil/lymphocyte ratio and endometrial sampling results were compared in terms of outcome in women with postmenopausal bleeding. In addition, we aimed to determine the predictive value of endometrial thickness and neutrophil/lymphocyte ratio for predicting endometrial carcinoma. Material and methods: Our single-centered study was performed retrospectively. The study included 386 postmenopausal women admitted to our gynecology outpatient clinic for abnormal uterine bleeding between January 2015 and June 2017 and subjected to endometrial sampling. Results: The mean endometrial thickness for endometrial hyperplasia was calculated as 13 mm (min. 4 mm, max. 20 mm) and for endometrial carcinoma 17.19 mm (min. 8 mm, max. 27 mm). The neutrophil count and neutrophil/lymphocyte ratio (NLR) were significantly higher and the lymphocyte count was lower in the group with endometrial malignancy (p = 0.002, p < 0.001 and p = 0.011, respectively). None of the patients with endometrial thickness < 8 mm received an endometrial carcinoma diagnosis. The optimal cut-off value of endometrial thickness for detecting endometrial carcinoma was ≥ 13.50 mm, at which the sensitivity was 75% and specificity was 83.6%. The optimal cut-off value of NLR for detecting endometrial carcinoma was ≥ 2.20, at which the sensitivity was 81.3% and specificity was 60.5%. Conclusions: Co-evaluation of NLR with endometrial thickness determined by transvaginal sonography might be useful for predicting endometrial carcinoma.

Prediction of maternal near-miss in placenta previa: a retrospective analysis from a tertiary center in Ankara, Turkey

Abstract Aim: To determine risk factors for severe complications during and after cesarean delivery (CD) in placenta previa (PP). Methods: We reviewed retrospectively collected data from women with PP who underwent CD during a 6-year study period. We identified the complicated group based on the modified WHO near-miss criteria. Complicated and noncomplicated groups were compared considering clinical, laboratory, and sonographic features. Results: Thirty-seven of 256 cases classified as near miss consisting of 14 peripartum hysterectomies, 12 uterine balloon placements, 10 great artery ligations, and four B-lynch suture placement procedures without maternal mortality. Perioperative complications included surgical wound infections (n = 5), bladder injury (n = 4), pelvic abscess (n = 1), and uterine rupture (n = 1). Logistic regression analyses demonstrated following features to be associated with maternal near miss in PP: (1) coexistent abruption (aOR 13.2, 95% CI 5.8–75.3), (2) morbidly adherent placenta (aOR 11.92, 95% CI 3.24–43.82), (3) number of hospitalizations for vaginal bleeding (≥3) (aOR 8.88, 95% CI 3.32–26.69), and (4) transvaginal cervical length (CL) measurement <10th percentile (aOR 5.5, 95% CI 2.1–15.4). Conclusion: Short cervical length, recurrent vaginal bleeding, morbidly adherent placenta, and concurrent placental abruption are independent predictors for subsequent severe maternal morbidity in PP cases. Early identification of these risk factors during PP follow-up may improve maternal outcome.

Risk factors for relaparotomy after cesarean delivery and related maternal near-miss event due to bleeding

Abstract Aim: To define the risk factors for relaparotomy after cesarean delivery (RLACD) and related maternal near-miss event due to bleeding. Methods: In this retrospective descriptive case-control study, women who underwent RLACD (n = 46) only for bleeding between 2012 and 2017 were reviewed. Factors that could predict relaparotomy and related near-miss event were evaluated. Maternal characteristics, laboratory findings and surgical features were compared with a control group (n = 230) that included noncomplicated cesarean deliveries (CD). Logistic regression analysis was used to identify independent factors for relaparotomy. Results: RLACD for bleeding was required in 0.26% of patients and the incidence increased gradually over years (0.16% in 2013 versus 0.44% in 2017). Mean interval between CD and subsequent relaparotomy was 15.7 ± 3.2 hours. The sources of bleeding in descending order of frequency included; uterine fundus and placental bed (39.1%), cervix (21.7%), undetermined (17.3%), superior epigastric artery (13%), superficial epigastric artery (8.1%). Longer duration of CD (adjusted odd ratio (aOR) 1.82, 95% CI 1.02–2.53), increased number of prior CDs (aOR 2.51, 95% CI 1.09–5.78), preeclampsia (aOR 3.48, 95% CI 1.21–7.19) were found to be independent risk indicators for RLACD. Moreover, longer duration of interval between CD and relaparotomy (p = .005), longer relaparotomy duration (p = .012) and greater drop in hemoglobin level (p = .001) were found to be the predictors of maternal near-miss event. Conclusions: Patients with identified risk factors should be managed properly in order to prevent relaparotomy and near-miss event after CD. Also, urgent decision of surgical intervention might reduce the risk of maternal near-miss event.