Murat Gözüküçük

Uterine rupture at the 29th week of subsequent pregnancy after hysteroscopic resection of uterine septum

OBJECTIVE To describe a patient with uterine rupture in the subsequent pregnancy after hysteroscopic resection of a uterine septum. DESIGN Case report. SETTING University hospital. PATIENT(S) A 30-year-old nulliparous woman, with a history of a first trimester spontaneous abortion, hysteroscopic uterine septum resection by cutting diathermy using the operating hysteroscope, and a second hysteroscopic procedure for a residual septum, was admitted to our clinic with symptoms of hemodynamic shock at the 29th week of gestation. INTERVENTION(S) Immediate laparotomy was performed. MAIN OUTCOME MEASURE(S) Uterine rupture in the second trimester of the subsequent pregnancy with fetal loss. RESULT(S) Midfundal complete uterine rupture was observed at the site of the resected uterine septum, accompanied by an extrauterine exanimate fetus. CONCLUSION(S) Uterine rupture may occur in pregnancies after hysteroscopic resection of the uterine septum. Clinicians who perform this procedure, especially in the cases with repeated procedures using cutting diathermy, must warn and inform their patients about the risks of their later pregnancies.

Fetal hydrops and anemia as signs of Down syndrome

Before the 20th week of gestation, the most common cause of nonimmune hydrops fetalis is chromosomal abnormalities. Herein, we report a case of fetal hydrops, anemia, and intrauterine growth retardation that presented at 27 weeks of gestation with a negative chromosomal abnormality screening. Cordocentesis and karyotype analysis revealed fetal pancytopenia and Down syndrome. Down syndrome rarely presents with fetal hydrops and anemia. Therefore, when hydrops and anemia are diagnosed, especially in the second trimester of gestation, the possibility of Down syndrome should be kept in mind. In addition, if the pregnancy results in a live birth, the baby should be examined for transient abnormal myelopoiesis.

Rare presentation of ectopic pregnancy following IVF-ET: live twin gestation in the same fallopian tube

We report a case of a twin ectopic pregnancy (EP) after in vitro fertilization and embryo transfer (IVF-ET). A 24-year-old nulligravida presented with lower abdominal pain and vaginal bleeding 4 weeks after embryo transfer. Serum β-HCG levels were 40 IU/mL, 90 IU/mL, and 1970 IU/mL on ET days 12, 14, and 23, respectively. Ultrasound examination revealed two ectopic gestational sacs with fetal heart beats in the left adnexa, without evidence of intrauterine pregnancy. At laparoscopy, one isthmic and another ampullary sac were detected in the left tube and left salpingectomy was performed. The patient was discharged healthy on postoperative day 2. Albeit extremely rare, ectopic pregnancies with abnormal presentation can be encountered following IVF-ET. Single embryo transfer may be advised to protect from ectopic pregnancies after IVF-ET.

Are gonadotropin-releasing hormone analogs safe and effective for protection of ovarian reserve against chemotherapeutic insult?

We read with great interest the study by PotologNahari and colleagues about the effectiveness of a novel treatment which utilizes a combination effect of agonistic and antagonistic gonadotropin-releasing hormone (GnRH) analogs to protect against chemotherapy-induced gonadal failure [1]. However, we think that some important findings of the study merit further evaluation. It appears that 5/9 (55.5%) patients (nos. 3, 4, 5, 6 and 7) already had diminished ovarian reserve as reflected by high basal serum level of folliclestimulating hormone (412 IU/ml) or estradiol (475 pg/ml) [2,3]. The follow-up ranged from 3 to 11 months from completion of chemotherapy, which is an extremely short time period to draw a definitive conclusion about whether ovarian reserve is affected. Significant ovarian compromise has been consistently demonstrated in pubertal/prepubertal children receiving high-dose chemotherapy for hematopoietic stem cell transplantation, despite having a larger primordial follicle pool than adult women [4]. In the only prospective randomized human study, the protective role of GnRH analog co-treatment was demonstrated as ineffective [5]. Moreover, the cumulative dose of the alkylating agent, which is among one of the most important parameters determining the risk of ovarian damage [6], was not specified in the study. It was stated that 8/9 patients regained normal basal hormonal profile within 3–6 months after the completion of chemotherapy. Normalization of a hypergonadotropic hormonal milieu within a short time after completion of chemotherapy, or even during the course of chemotherapy, is not an uncommon finding [6]. The absence of immediate ovarian failure does not mean that the gonads are unaffected by the chemotherapeutic insult. It is possible that ovarian suppression with GnRH analogs preserves follicles that have initiated to grow. However, growing follicles not only constitute less than 10% of the primordial follicle reserve at any given time in the ovary, but once growth has been initiated, they are destined either to become atretic or to ovulate. It is quite possible that GnRH analog cotreatment delays the ultimate fate of these follicles, therefore erroneously giving the impression that ovarian function is protected in the short run. In parallel with these findings, a rodent study showed that ovulation may still occur despite the loss of half of the follicle pool [7]. Moreover, the direct effects of GnRH analogs on human ovaries are not clearly understood. GnRH receptors were demonstrated to be expressed by ovarian surface epithelial cells, human granulosa cells and human ovarian cancer cells, which mediate antigonadotropic, antiproliferative and antiapoptotic effects [8–10]. Pro-apoptotic effects of GnRH analogs on human granulosa lutein cells and cancer cells have also been demonstrated [10]. However no evidence showed that GnRH receptors are expressed in primordial follicles. An interesting animal study demonstrated acute depletion of the murine primordial follicle reserve by GnRH antagonists [9], while in human granulosa lutein cells a GnRH antagonist increased DNA synthesis and blocked the pro-apoptotic effect of a GnRH agonist [10]. Such a number of additional controversial findings on the effects of GnRH analogs on human ovaries make it advisable to test these compounds for use in ovarian protection in carefully designed clinical trials [11].

Ektopik Gebelik Olgularında Tanı Kriterlerinin Tedavi Seçimine Etkisi

Amac: Ektopik gebelik olgularinda tedavi seciminde rol oynayan faktorleri belirlemek. Hastalar Ve Yontem: Ankara Universitesi Tip Fakultesi Kadin Hastaliklari ve Dogum Anabilim Dali’nda Ocak 1998-Temmuz 2006 tarihleri arasinda ektopik gebelik tanisi konulan ve tedavi edilen toplam 150 hastanin verileri retrospektif olarak degerlendirildi. Sonuclar: Toplam 150 hastanin 109’una (%72,9) cerrahi uygulanirken, 23 hasta (%15,3 ) parenteral Metotreksat ile tedavi edildi. Onsekiz hasta (%11,8 ) tedavi verilmeden izlendi. Cerrahi uygulanan 109 hastanin 83’une (%76,1) laparoskopi, 26’sina (%23,9) laparotomi uygulandi. Laparoskopi yapilan 55 hastaya (%66) salpinjektomi, 23 hastaya (%27,6) salpingostomi yapilirken, kalan 5 hastada (%6,4) fimbrial yerlesim gosteren gebelik materyali fimbrial uctan ekstirpe edildi. Laparotomi olan butun hastalara salpinjektomi yapildi. Tedavi verilmeden takip edilen hastalarda bhCG duzeyleri anlamli olarak daha dusuktu (P < 0,05). Laparotomi yapilan hastalarda b-hCG duzeyi, laparoskopi yapilan gruba gore anlamli olarak yuksekti (P < 0,05). Nullipar hastalarda metotreksat tedavivisi ve tedavisiz izlem, cerrahi tedaviye gore daha yuksek oranda tespit edildi (P < 0,05). Sonuc: Ektopik gebelik tedavisinde, hastanin klinigi ve fertilite durumu uygun tedavi seciminde goz onunde bulundurulmasi gereken noktalardir. β-hCG duzeyleri degiskenlik gostermesine ragmen genellikle klinikle yakindan iliskilidir.