Semih Özeren

Diagnostic accuracy of real‐time 3D sonography in the diagnosis of congenital Mullerian anomalies in high‐risk patients with respect to the phase of the menstrual cycle

To compare the diagnostic accuracy of 2‐dimensional sonography (2DUS) and real‐time 3‐dimensional sonography (3DUS) in the diagnosis of congenital mullerian defects (CMD) with respect to the phase of the menstrual endometrium.

Misoprostol 50 μg Sublingually versus Vaginally for Labor Induction at Term: A Randomized Study

Objective: To compare the efficacy of misoprostol 50 µg vaginally and 50 µg sublingually for labor induction at term. Materials and Methods: One hundred and sixty women were randomized to receive misoprostol 50 µg vaginally (n = 80) or 50 µg sublingually misoprostol (n = 80). The doses were given every 4 h (maximum 6 doses). Primary outcome measure was number of cesarean deliveries. Induction to delivery time, delivery within 24 h, the number of misoprostol doses given; the need for oxytocin augmentation, tachysystole and uterine hyperstimulation rates and neonatal outcomes were secondary outcome measures. Results: The mean induction to delivery time was 748 ± 379 min in the vaginal group and 711 ± 425 in the sublingual group (p = 0.56). The number of women delivering within 24 h was 73 (91.3%) in the vaginal group and 74 (92.5%) in the sublingual group (p = 0.78). The mean number of misoprostol doses required was significantly higher in the sublingual group (1.9 ± 1.2) compared with the vaginal group (1.1 ± 0.4; p < 0.001). More women in the sublingual group experienced tachysystole (n = 14, 17.5%) compared with the vaginal group (n = 3, 3.8%; p = 0.005). Seven cases (8.8%) in the vaginal group and 12 cases in the sublingual group (15%) required emergent cesarean delivery for fetal heart rate abnormalities (p = 0.22). Other neonatal outcomes including umbilical artery pH, Apgar scores and intensive care unit admission were similar in the two groups. Conclusion: Sublingual misoprostol is as efficacious as vaginal misoprostol for induction of labor. More frequent tachysystole is observed with misoprostol 50 µg sublingually, but neonatal outcomes are similar.

Pure nongestational choriocarcinoma of ovary

IntroductionPrimary ovarian choriocarcinoma arising presumably from a germ cell is extremely rare. Besides arising gestationally or nongestationally, it may be pure or mixed with other germ cell tumors like immature teratoma, dysgerminoma, polyembryoma.Case report and discussionWe present a case of a 22-year-old woman diagnosed with pure nongestational choriocarcinoma of the ovary with a review of the literature and discussion of its origin.

Magnetic resonance imaging and angiography for the prerupture diagnosis of rudimentary uterine horn pregnancy.

Magnetic resonance (MR) imaging and MR angiography were used for the differential diagnosis and preoperative planning of a 17 weeks of age rudimentary horn pregnancy. A 26-year-old primigravida was referred to our hospital with a preliminary diagnosis of abdominal pregnancy. After an inconclusive ultrasound evaluation we were able to identify a rudimentary horn pregnancy, extent of the placental invasion, and the vascular supply via MR imaging and time of flight sequence MR angiography. The obtained data were also used for preoperative planning, which resulted in an uncomplicated, prerupture laparotomy for pregnancy termination and a healthy female.

The effects of human amniotic membrane and fibrin sealant in the prevention of postoperative adhesion formation in the rabbit ovary model.

Summary: The study group consisted of 29 female, white New Zealand rabbits. The rabbits were randomized into 3 groups and a midline laparotomy was performed in order to make a 4–5 mm long lesion using a scalpel in both ovaries. In Group 1, both of the ovaries were left uncovered. In Group 2, the right ovaries were covered by human amniotic membrane graft. In Group 3, 0.1–0.2 mL of Tisseel solution was applied to the lesion in the right ovaries. No medication was applied to the left ovaries in any of the groups and thus this ovary acted as an individual control. After 2 weeks the adhesion scores were graded by relaparotomy in a blind manner. Fibrin sealant showed a significant reduction in postoperative adhesion formation compared with the amniotic membrane graft and control groups (p<0.001). Therefore, it can be concluded that fibrin sealant can be used as an adjuvant during reproductive surgery.

Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy.

Implantation of conception material within a cesarean section scar is an extremely rare form of ectopic pregnancy with devastating complications, such as uterine rupture and intractable bleeding. Both 2‐D and 3‐D transvaginal ultrasonographic devices are used adequately for precise diagnosis, but there is still a lack of consensus concerning management strategies. No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29‐year‐old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum β‐hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.

Unsuccessful management of acardiac fetus with intrafetal alcohol injection.

Twin reversed arterial perfusion (TRAP) sequence is an extreme form of twin-to-twin transfusion in which the normal ‘pump’ twin perfuses its acardiac cotwin. The pump twin has a 50% mortality rate due to congestive heart failure, and polyhydramnios and preterm delivery are further obstetric complications. The risk of an adverse pregnancy outcome is increased when the ratio of acardiac twin : pump twin weight exceeds 70%. Management of TRAP sequence includes elective termination, observation and follow-up using ultrasound or cardiotocography, digoxin therapy for cardiac failure of the pump twin and interventions that target the blood supply of the acardiac fetus. Coagulation of the vascular anastomosis under sonoendoscopic control and percutaneous umbilical cord ligation are invasive therapeutic options. Percutaneous intrafetal alcohol injection has also been reported as a simple and less invasive procedure1,2. We report here our unsuccessful management using intrafetal alcohol injection of an acardiac acephalic twin pregnancy in a 16-year-old woman, gravida 1 para 0, at 12 weeks of gestation. On admission, ultrasound evaluation demonstrated a monochorionic twin pregnancy in which one of the fetuses had no head and upper extremities but normal mobile lower extremities (Figure 1) and significant edema around the trunk. Despite the absence of the heart, blood flow in the

Acute fatty liver of pregnancy complicated with disseminated intravascular coagulation and haemorrhage: a case report

Acute fatty liver of pregnancy (AFLP) is a rare disorder of unknown aetiology that is diagnosed typically in the third trimester or early postpartum period. The incidence is estimated to be 1/6692–1/13,328. The obstetric team must have a high index of suspicion of this pathology, particularly in the presence of clinical and laboratory findings, such as nausea, vomiting, jaundice, increased serum transaminase levels, increased prothrombin time and hypoglycaemia. Early diagnosis followed by prompt delivery and supportive care provides significantly improved maternal and perinatal outcome. Delay in diagnosis of this obstetric emergency may lead to rapid progression to hepatic failure, disseminated intravascular coagulation (DIC), haemorrhage, encephalopathy, multiple organ failure and finally death. The case of a 34‐year‐old woman, gravida 3, para 2, with AFLP complicated with DIC is presented herein with a review of literature and discussion of its origin.

Reduction in caesarean delivery with fetal heart rate monitoring and intermittent pulse oximetry after induction of labour with misoprostol

Objective. To integrate intermittent fetal pulse oximetry (FPO) to intrapartum fetal assessment and reduce the rate of caesarean sections. Methods. A randomised controlled trial using 37 weeks as a restriction point was conducted in 230 women induced with misoprostol. One hundred-fourteen were assessed with intermittent FPO plus fetal heart rate (FHR) monitoring (study group) and 116 were assessed with FHR monitoring alone (control group). The primary outcome measure was caesarean delivery rates. Secondary outcome measures included induction to delivery interval, number of emergency caesarean deliveries performed for fetal non-reassuring FHR patterns and neonatal outcomes. Results. There was a reduction both in the overall caesarean deliveries (study n = 18, (15.7%); vs. control n = 31 (26.7%); p = 0.04), and the rate of caesarean deliveries performed for non-reassuring fetal status in the study group (study n = 11, (9.6%); vs. control n = 23 (19.8%); p = 0.03). Induction to delivery interval was similar in between the groups (759 ± 481 min in group 1; vs. 735 ± 453 min in group 2 respectively; p = 0.69). Conclusion. Intermittent FPO in misoprostol induced deliveries decreases both total caesarean rate and the caesarean rate due to non-reassuring FHR patterns.

Efficacy of methotrexate and misoprostol for early abortion

BACKGROUND Medical termination of pregnancy (medical abortion) as an alternative to surgical abortion has many advantages since it does not require anesthetics and there is no risk of cervical laceration or uterine perforation. In the present study, we evaluated the efficacy of methotrexate and intravaginally administered misoprostol for early abortion. METHODS The study population consisted of 32 women seeking abortion of a normal intrauterine pregnancy of 8 weeks or less documented by ultrasound. The dose of methotrexate was 50 mg/m2 intramuscularly and the dose of misoprostol was 800 micrograms intravaginally. The final outcome of treatment was evaluated on day 14 or 16, and an abortion was considered successful if pregnancy was terminated without a surgical procedure. RESULTS Abortion occurred in only 23 (71.8%) of 32 women. There were 9 failures (28.1%); 3 were ongoing pregnancies (9.3%) and 6 were incomplete abortions (18.7%) requiring suction curettage. After the exclusion of treatment failures, the mean duration of vaginal bleeding was 16.3 +/- 2 days. No serious side effects occurred as a result of methotrexate and misoprostol treatment. CONCLUSION The use of methotrexate and intravaginal misoprostol for the termination of pregnancy requires larger studies to determine the safety and efficacy of this medical abortion, a comparison with RU 486 in prospective controlled randomized trials is necessary.