Mustafa Ulubay

Imperforate hymen causing hematocolpos and acute urinary retention in an adolescent girl

Pelvic and abdominal pain is especially common in adolescent age group. Differential diagnosis could be gastrointestinal, renal, gynecological, and psychosomatic causes. The inability to pass urine, which is termed as acute urinary retention (AUR), is an uncommon cause of pelvic pain. The etiology of AUR is age dependent; and in childhood, severe voiding dysfunction may be drug induced with antihistamines or anticholinergic drugs, psychogenic, related to viral infections, congenital anomalies, neurological bladders, or mechanical compression of the urethra via the mass of pelvis [1,2]. Hematocolpos is defined as the accumulation of menstrual blood in the vagina instead of its expulsion, which is usually because of an imperforate hymen. The incidence of imperforate hymen as a congenital obstructive abnormality of the female genital tract is 1:2,000 [3]. We report a case of an adolescent girl who complained of pelvic pain resulting from AUR because of an imperforate hymen, which also mimicked pelvic mass at the differential diagnosis. A 15-year-old girl referred to our tertiary center obstetrics and gynecology department from emergency service with the symptoms of acute severe lower abdominal pain and inability to pass urine. The tentative diagnosis in emergency service was a semisolid pelvic mass measuring about 12 7 9 cm diagnosed by transabdominal ultrasonography. Gynecological examination was not performed at the emergency service; instead, the patient was referred to the obstetrics and gynecology department of our hospital. At the admission of the patient, she seemed very uncomfortable and was cramping with an intermittent pelvic pain. Her temperature was 37 C, pulse rate was 90/min, respiration rate was 18/min, and the blood pressure was 110/78 mmHg. Her personal and family history revealed nothing unusual except the

Fetal Ovarian Cysts Diagnosed During Prenatal Ultrasound Screening

OBJECTIVE To discuss the follow-up and management of fetal ovarian cysts (FOCs) and review the current literature. CASE REPORT A 26-year-old, gravida 2, para 0, abortus 1, Rh-negative patient was diagnosed with bilateral FOCs during ultrasound examination at 32 weeks gestation. Fetal nuchal translucency measured at 12 weeks gestation was 1.2 mm, and a combined triple test for trisomy 21 suggested a 1/800 risk. She was regularly monitored at our antenatal outpatient clinic, and the course of her pregnancy was uncomplicated until 32 weeks gestation, when bilateral FOCs were diagnosed. Because of cephalopelvic disproportion, a cesarean section was performed at 39 weeks gestation and a 3,680-g Rh-positive female baby was delivered. The baby was admitted to the neonatal care unit and was monitored by pediatricians. Ultrasound examination in the second postpartum month revealed spontaneous regression of the bilateral ovarian cysts. CONCLUSION Although FOCs are not usually life-threatening, the risk of losing the ovaries due to torsion during the neonatal period and the resulting sexual development disorders and infertility are very disturbing.

Increased neopterin level and chitotriosidase activity in pregnant women with threatened preterm labor

Abstract Objectives: To determine whether the cellular inflammatory markers of activated macrophages, neopterin (NEO), chitotriosidase activity and the acute-phase inflammatory marker C-reactive protein (CRP) are elevated in pregnancy with threatened preterm labor (TPL). Methods: Thirty-two pregnant women with TPL and 32 women with uncomplicated pregnancy (UP) were included this study. The primary aim was to compare the NEO, chitotriosidase activity and CRP levels between women with TPL and women with UP. Results: NEO levels were all significantly elevated in patients with TPL compared to UP (median 25–75%; 9.61 [8.47–12.29] versus 4.46 [3.59–6.92], respectively; p < 0.001). Chitotriosidase activity was significantly elevated in pregnant women with TPL compared to UP (median 25–75%; 59.00 [38.00–87.25] versus 43.50 [23.25–65.25], respectively; p = 0.036). However, CRP levels were not different in women with TPL compared to UP (p = 0.573). Furthermore, a significant moderate negative correlation was found between delivery week and NEO level (r = −0.557, p = 0.001). However, a significant correlation was not seen between delivery week and chitotriosidase activity (r = −0.042, p = 0.741). Conclusions: Inflammatory markers such as NEO and chitotriosidase activity, which are markers of macrophages, are more elevated in pregnant women with TPL than in women with UP. These data suggest that there are striking increases in inflammation and cellular immune activation in TPL.

Effect of injectable medroxyprogesterone acetate and etonogestrel implants on GABA-A and serotonin receptors in white and gray matter of the brain: experimental study in rats.

Abstract The aim of this study was to evaluate the time-dependent effect of progesterone-only contraceptives on the brain and to obtain an improved understanding of mood disorders experienced under this medication. A total of 66 Wistar albino rats were divided into three groups: etonogestrel (ENG) implant (group 1, n = 30); depot medroxyprogesterone acetate (MPA)-injectable (group 2, n = 30); and control (group 3, n = 6) groups. Groups 1 and 2 were each divided into five subgroups, which were examined every 10 d for up to 50 d after medication administration, to evaluate its time-dependent effect. There was no difference in terms of gamma-aminobutyric acid (GABA) and serotonin immunohistochemical staining in white and gray matter among the subgroups of group 1. In group 2, there was a significant decrease in serotonin receptor staining intensity in white and gray matter on day 50, when compared to the control group (p = 0.041). When the subgroups of group 2 were compared, there was a significant decrease in serotonin receptor staining intensity in white and gray matter on days 40 and 50 when compared to day 10. In conclusion, we showed that ENG and MPA have no effect on apoptosis and GABA-A receptors in the brain. We also showed that MPA has time-dependent effects on serotonin receptors, which may be a possible mechanism involved in mood disorders during long-term usage of injectable progesterone-only contraceptives.

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).

UNILATERAL TUBAL ECTOPIC TWIN PREGNANCY

Ectopic pregnancies develop when conception products implant somewhere other than in the endometrial cavity. If these pregnancies are not diagnosed and treated early, they can affect fertility and threaten the lives of otherwise healthy women. Twin pregnancies develop in approximately 1 in every 80 spontaneous pregnancies, and heterotopic pregnancies occur in about 1 in every 7,000 spontaneous pregnancies [1]. The probability of developing a unilateral tubal twin pregnancy has been calculated as 1 in every 125,000 spontaneous pregnancies. Most unilateral tubal twin gestations are reported to be monochorionic and monoamniotic [2]. A 24-year-old patient with a 5-week history of amenorrhea was admitted to our clinic with a complaint of left pelvic pain and vaginal bleeding which had lasted for 3 days. At admission, the patient was generally well and was conscious, cooperative and well-oriented. Her medical history revealed that she had been married for 3 months and was nulligravid, but used no contraception and had been planning on having children. The patient’s blood pressure was 120/80 mmHg, her pulse was 84 beats/minute, and her temperature was 37°C. Pelvic examination revealed extrauterine vaginal bleeding, closed cervical os, pain on cervical movement during manual examination, and left adnexal fullness and sensitivity. Abdominal examination revealed only left lower quadrant sensitivity. The left ovary appeared normal, but transvaginal ultrasound demonstrated an approximately 4 cm-sized left juxtauterine mass and free fluid in the left paraovarian area. Laboratory findings included a β-human chorionic

Are serum gamma-glutamyl transferase, high-sensitivity C-reactive protein, and ischaemia-modified albumin useful in diagnosing PCOS?

abstract We assessed the serum levels of gamma-glutamyl transferase (GGT), high-sensitivity C-reactive protein (hsCRP) and ischaemia-modified albumin (IMA) in patients with polycystic ovary syndrome (PCOS). Fifty-three patients with PCOS were included in our study along with 40 women with no PCOS as the control group. The patients were divided according to their body mass index (BMI). GGT levels were significantly higher in the women with PCOS than the women in the control group (p < 0.05). They were also significantly higher in the PCOS women who were normoweight and overweight than the normoweight and overweight women in the control group (p < 0.001). There was no significant difference in the circulating levels of hsCRP and IMA between the women with PCOS and the controls or between the normoweight and overweight subgroups. GGT may be associated with the diagnosis of PCOS when the threshold is set at >15.5 U/L. With the application of this threshold, raised GGT levels had 83% sensitivity (95% CI 0.70–0.90) and 67.5% specificity (95% CI 0.52–0.79), for the diagnosis of PCOS. In our study, GGT levels were elevated in the PCOS patients independent of BMI and could thus be an important marker of PCOS.

Safety, Efficiency, and Outcomes of Perineoplasty: Treatment of the Sensation of a Wide Vagina

Background. The sensation of a wide vagina is a common problem for women after childbirth. As its etiology is unknown, there is no uniform management strategy. We hypothesized that, rather than vaginal laxity, the cause was level 3 pelvic support deficiency. Methods. This retrospective study compared preoperative and postoperative genital hiatus length, perineal length, and total vaginal length in patients treated with perineoplasty for the sensation of a wide vagina. A telephone survey was used to determine postoperative patient and male partner satisfaction rates. Results. Mean age of patients was 48 (26–68) years; mean body mass index (BMI) was 25.3 (17.6–33.2); and mean parity was 2.5 (2–5). Preoperative and postoperative genital hiatus, perineal length, and total vaginal length were 4.62 and 3.18 (p < 0.01), 3.06 and 4.04 (p < 0.01), and 9.43 and 9.43 (p = 0.882), respectively. At the 6-month follow-up, the success rate of the perineoplasty procedure was 87.9%; according to a visual analog scale, partner satisfaction rate was 92.6%. Ten percent (n = 4) of patients said they experienced dyspareunia during sexual intercourse at the introitus of the vagina. Conclusion. With low dyspareunia rates, low complication rates, high patient satisfaction, and satisfactory anatomical success, perineoplasty can be considered successful for treatment of the sensation of a wide vagina.

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.