Nuri Danisman

Emergency hysterectomy in modern obstetric practice Changing clinical perspective in time

OBJECTIVE Emergency hysterectomy in obstetric practice is generally performed in the setting of life-threatening hemorrhage. A retrospective review based on hospital data of 67 patients undergoing emergency peripartum hysterectomy over 10 years was undertaken. METHODS Comparison of two different time periods regarding the incidence and the indications of obstetric hysterectomies was made. RESULTS The number of patients with hysterectomy in the first 5 years of the study period (1985-1989) was 43 and during the last 5 years (1990-1994) it was 24. The incidence of hysterectomy during 1985-1989 was 1 in 2495 deliveries and the most common indication for hysterectomy was uterine atony (42%) followed by placenta accreta (25.5%) and uterine rupture (21%). On the other hand, the incidence of hysterectomy during 1990-1994 was 1 in 4228 deliveries and the ranking of indications of hysterectomy was slightly different from group 1 as mostly placenta accreta (41.7%) followed by uterine atony (29.2%). The maternal mortality rate was 4.5% in this series. CONCLUSION This study showed that over the last decade the incidence of emergency hysterectomy in obstetric practice has declined in our clinic due to availability of high standard obstetric care and more liberal use of cesarean section at risk deliveries, better controlled use of oxytocin and internal iliac artery ligation.

Role of oxidative stress in preeclampsia and intrauterine growth restriction

Aim:  The aim of the present study was to evaluate the role of oxidative stress and DNA damage in preeclampsia and intrauterine growth restriction (IUGR).

Are clinical symptoms more predictive than laboratory parameters for adverse maternal outcome in HELLP syndrome

Background. To determine the risk factors for adverse maternal outcome among women with HELLP syndrome. Methods. Sixty‐one pregnancies with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome diagnosed antenatally were reviewed between 2003 and 2005. Maternal outcomes analyzed included eclampsia, abruptio placentae, disseminated intravascular coagulopathy (DIC), acute renal failure, need for transfusion of blood products, cesarean delivery and maternal death. Risk factors included maternal age, parity, gestational age at diagnosis, mean arterial blood pressure, headache, visual changes, nausea‐vomiting, epigastric pain, blood platelet count (≤50,000 versus>50,000 cells/mm3), and peak serum levels of aspartate aminotransferase. Results. Eclampsia was present in 52%, abruptio placentae in 11%, and DIC in 8% of 61 women with HELLP syndrome. 23% women required transfusion of blood products, 15% had acute renal failure, and 73% had cesarean section. Women with eclampsia had significantly more headache, nausea‐vomiting, visual changes and epigastric pain (p<0.05). Transfusion was significantly more frequent among women with blood platelet counts≤50,000 cells/mm3 (33 versus 21%; p<0.05). Women with a platelet count≤50,000 cells/mm3 had a higher rate of DIC compared to women with a platelet count>50,000 cells/mm3 (33.3 versus 3.8%; p<0.05). In women with acute renal failure and abruptio placentae, there were no significant differences in all the variables studied between those with and without these complications. Conclusions. Clinical symptoms, such as headache, visual changes, epigastric pain and nausea‐vomiting, are more predictive than laboratory parameters for adverse maternal outcomes.

Circulating levels of copeptin, a novel biomarker in pre‐eclampsia

Aims:  Increasing evidence supports the participation of metabolic syndrome and insulin resistance in the pathogenesis of pre‐eclampsia. Copeptin is co‐synthesized with vasopressin and is a new and promising novel marker of metabolic syndrome and insulin resistance. Our aim was to investigate copeptin levels in normotensive pregnant, mild and severe pre‐eclamptic women.

Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section

BACKGROUND An intrauterine device (IUD) is an effective reversible form of contraception. We determined the efficacy and safety of immediate postplacental IUD insertion during cesarean section. STUDY DESIGN Two hundred forty-five women with term pregnancies delivering by cesarean section between September 2006 and December 2007 were included in the study. A copper IUD (TCu 380A) was inserted using a ring forceps within 10 min of removing the placenta. The participants were examined before hospital discharge and at 6 weeks, 6 months and 12 months postpartum. RESULTS None of the patients were lost to follow-up. There was one case of an unplanned pregnancy (0.4%). There were no serious complications associated with immediate IUD insertion during cesarean section. The cumulative rates of expulsion, removal for bleeding/pain and other medical reasons were 17.6, 8.2 and 2.4 per 100 women per year, respectively. The continuation rates were 81.6% and 62% at 6 and 12 months, respectively. CONCLUSION Immediate postplacental IUD insertion during cesarean section provides adequate protection against pregnancy. However, greater than one fourth of the participants discontinued IUD use due to spontaneous expulsion or other medical reasons.

Association of maternal serum high sensitive C‐reactive protein level with body mass index and severity of pre‐eclampsia at third trimester

Aim:  To assess a maternal serum level of high sensitive C‐reactive protein (hs‐CRP) as a useful clinical parameter in prediction of pre‐eclampsia severity and, to evaluate the correlation between hs‐CRP and body mass index (BMI).

Increased MPV Is Not a Significant Predictor for Preeclampsia During Pregnancy

Preeclampsia, defined as the presence of hypertension and proteinuria, is usually related with maternal and neonatal adverse effects. However, the exact predictor of preeclampsia is still lacking. Even though there are some conflicting data, mean platelet value or MPV, that is, platelet ratio with or without Doppler velocimetry was determined as highly sensitive markers for preeclampsia. We aimed to investigate the utility of MPV in prediction of preeclampsia.

Asymptomatic Bacteriuria and Antibacterial Susceptibility Patterns in an Obstetric Population

Introduction. Asymptomatic bacteriuria (ASB), occurring in 2–11% of pregnancies, is a major predisposition to the development of pyelonephritis, which is associated with obstetrical complications, such as preterm labor and low birth weight infants. The aim of this study was to determine the prevalence of ASB, the antibacterial susceptibilities of the isolated microorganisms and the associated risk factors in an outpatient clinical setting in Zekai Tahir Burak Womens Health Education and Research Hospital in Ankara, Turkey. Material and Methods. Between December 2009 and May 2010, pregnant women admitted to the antenatal outpatient clinic were included in this study. The results of a complete urine analysis, midstream urine culture and antibacterial susceptibility were evaluated. Results. Of the 2011 pregnant women included, 171 had ASB (8.5%). E. coli was the most frequently isolated microorganism (76.6%), followed by Klebsiella pneumonia (14.6%). Both microorganisms were highly sensitive to fosfomycin, sensivity being 99.2% for E. coli and 88% for Klebsiella pneumonia. Conclusions. In this certain geographical region, we found E. coli as the most common causative agent of ASB in the obstetric population and it is very sensitive to fosfomycin. We recommend fosfomycin for ASB in pregnant women due to its high sensitivity, ease of administration and safety for use in pregnancy.

Emergency peripartum hysterectomy

PurposeTo determine the incidence, indications, risk factors and complications of peripartum hysterectomy in a tertiary teaching hospital.MethodsThe medical records of 73 patients who had undergone emergency peripartum hysterectomy between 2003 and 2008 were reviewed retrospectively. Maternal characteristics and characteristics of the present pregnancy and delivery, hysterectomy indications, operative complications, postoperative conditions and maternal outcomes were evaluated.ResultsThere were 73 emergency peripartum hysterectomies out of 114,720 deliveries, a rate of 0.63 per 1,000 deliveries. Eleven hysterectomies were performed after vaginal delivery (0.12/1,000 vaginal deliveries) and the remaining 62 hysterectomies were performed after cesarean section (2/1,000 cesarean sections). The most common indication for hysterectomy was placenta previa and/or accreta (31 patients, 42.4%), followed by uterine atony (26 patients, 35.6%). In this study, 22 of 29 patients (75.8%) with placenta previa and 12 of 16 patients (75%) with placenta accreta had previously had cesarean sections. Cesarean section is associated with placenta previa and accreta, which are the most common causes of emergency peripartum hysterectomy.ConclusionThe increase in the cesarean delivery rate is leading to an increase in the rate of abnormal placentation (placenta previa and accreta), which in turn give rise to an increase in the peripartum hysterectomy rate. Cesarean section itself is also a risk factor for emergency peripartum hysterectomy. Therefore, every effort should be made to reduce the cesarean rate by performing this procedure only for valid clinical indications. The risk factors for peripartum hysterectomy should be identified antenatally. The delivery and operation should be performed in appropriate clinical settings by experienced surgeons when risk factors are identified.

Outcomes after cesarean myomectomy versus cesarean alone among pregnant women with uterine leiomyomas

To determine whether myomectomy during cesarean delivery is safe and feasible among pregnant women with leiomyomas.