Serdar Yalvac

Intravenous versus oral iron for treatment of anemia in pregnancy: a randomized trial.

OBJECTIVE: The aim of this study was to compare the efficacy of intravenous iron to oral iron in the treatment of anemia in pregnancy. METHODS: In this randomized open-label study, 90 women with hemoglobin levels between 8 and 10.5 g/dL and ferritin values less than 13 &mgr;g/L received either oral iron polymaltose complex (300 mg elemental iron per day) or intravenous iron sucrose. The iron sucrose dose was calculated from the following formula: weight before pregnancy (kg) × (110 g/L – actual hemoglobin [g/L]) × 0.24 + 500 mg. Treatment efficacy was assessed by measuring hemoglobin and ferritin on the 14th and 28th days and at delivery, and the hemoglobin on the first postpartum day. Adverse drug reactions, fetal weight, hospitalization time, and blood transfusions were also recorded. RESULTS: Hemoglobin values varied significantly with time between groups (interaction effect, P < .001). The change in hemoglobin from baseline was significantly higher in the intravenous group than the oral group at each measurement; the changes with respect to subsequent hemoglobin were significantly higher on the 14th (P = .004) and 28th (P = .031) days. Ferritin values were higher in patients receiving intravenous iron throughout pregnancy. No serious adverse drug reactions were observed. Fetal weight and hospitalization time were similar in the 2 groups. Blood transfusion was required for only one patient in the oral group. CONCLUSION: Intravenous iron treated iron-deficiency anemia of pregnancy and restored iron stores faster and more effectively than oral iron, with no serious adverse reactions. LEVEL OF EVIDENCE: I

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial

BACKGROUND Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin. METHODS In this double-blind, non-inferiority trial, 31 055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Vietnam (two secondary-level and three tertiary-level facilities). 809 (3%) women were diagnosed with post-partum haemorrhage and were randomly assigned to receive 800 mug misoprostol (n=407) or 40 IU intravenous oxytocin (n=402). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS All randomly assigned participants were analysed. Active bleeding was controlled within 20 min after initial treatment for 363 (89%) women given misoprostol and 360 (90%) given oxytocin (relative risk [RR] 0.99, 95% CI 0.95-1.04; crude difference 0.4%, 95% CI -3.9 to 4.6). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) women receiving misoprostol and 123 (31%) receiving oxytocin (RR 1.12, 95% CI 0.92-1.37). Shivering (152 [37%] vs 59 [15%]; RR 2.54, 95% CI 1.95-3.32) and fever (88 [22%] vs 59 [15%]; 1.47, 1.09-1.99) were significantly more common with misoprostol than with oxytocin. Six women had hysterectomies and two women died. INTERPRETATION Misoprostol is clinically equivalent to oxytocin when used to stop excessive post-partum bleeding suspected to be due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour.

A quantitative evaluation of total antioxidant status and oxidative stress markers in preeclampsia and gestational diabetic patients in 24–36 weeks of gestation

OBJECTIVE To assess the plasma and serum maternal total antioxidant status, circulating levels of lipid peroxidation breakdown products (MDA), protein oxidation markers (AOPPs), myeloperoxidase (MPO) and lipid hydroperoxide (LHP) in preeclampsia, gestational diabetes mellitus (GDM) patients and compare them with noncomplicated normal pregnancies between 24 and 36 weeks of gestation. STUDY DESIGN 27 GDM, 27 preeclampsia and 29 noncomplicated singleton pregnancies were included. The blood samples were taken at the diagnosis of disease. RESULTS TAS was decreased in GDM and preeclampsia when compared to normal pregnancies. MDA levels were higher only in GDM group than normal pregnancies. AOPP levels were increased but MPO and LHP levels were not changed both in GDM and preeclampsia when compared to normal pregnancies. CONCLUSIONS We concluded that increased oxidative stress and reduction in antioxidant defense mechanisms may contribute to disease processes both in GDM and preeclampsia.

Prevalence of gestational diabetes mellitus and gestational impaired glucose tolerance in pregnant women evaluated by National Diabetes Data Group and Carpenter and Coustan criteria.

To determine the prevalence of gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) using National Diabetes Data Group (NDDG), and Carpenter and Coustan (CC) criteria.

Accuracy of frozen section diagnosis in borderline ovarian malignancy

This study was conducted to determine the accuracy of frozen section diagnosis in borderline ovarian tumors. Thirty-three patients were evaluated on the basis of frozen sections between February 1992 and December 1997. Frozen section diagnosis and final diagnosis were divided into three categories: for frozen section diagnosis: 1 = benign, 2 = borderline, 3 = ‘at least’ bordeline, and for final diagnosis: 1 = benign, 2 = borderline, 3 = cancer. Three patients with a benign diagnosis according to their frozen sections were reclassified as borderline in the final diagnosis and all of them were of the mucinous type. The frozen section diagnosis of tumors of borderline malignancy was inaccurate in 3 of 23 patients. Four of 7 patients with at least borderline according to their frozen section diagnosis had invasive cancer at the final diagnosis. The correlation between frozen section diagnosis and final pathological examination was 72.7% (24/33). We found 9% (2/22) inaccurate results in the serous type and 36.6% (4/11) in the mucinous type. The sensitivity and specificity of frozen section diagnosis were found to be 86.95 and 57.14%, respectively. We concluded that frozen section evaluation in identifying a borderline ovarian malignancy is accurate enough to exclude the presence of a benign pathology.

Embolization of Uterine Artery in Terminal Stage Cervical Cancers

Ligation of the hypogastric artery has been a standard and effective procedure in controlling massive bleeding in advanced cervical carcinoma. The authors wanted to demonstrate the selective use of embolization of hypogastric or uterine artery to achieve the same end result—the stoppage of vaginal bleeding. In a number of cases, surgical approach may not be appropriate either because of the critically ill patient or because of the highly deformed pelvic anatomy due to radiotherapy or to the recurrence of cancerous tissue. As an alternative therapy, we used selective embolization of the uterine artery in eight patients. In all the patients, embolization served to control bleeding. As the bleeding was brought under control, a gradual recovery of the patient was generally observed. The most common side-effect was temporary severe pain related to ischemia of tumoral tissue. Embolization may be regarded as an effective procedure, which can be used to control massive bleeding in selected cervical cancer patients.

Does brucellosis in human pregnancy increase abortion risk? Presentation of two cases and review of literature

Brucellosis is one of the most common zoonotic diseases that can be encountered during pregnancy. We present two pregnant women with brucellosis. One of them delivered normally and the other patient had an abortion. We reviewed the literature regarding the clinical course of brucellosis in pregnant women. Brucellosis during pregnancy can be associated with abortion, congenital and neonatal infections and infection of the delivery team. Therefore treatment with a combination of rifampicin and trimethoprim‐sulfamethoxazole should be started as soon as it is diagnosed to prevent possible complications.

Cigarette smoking and pregnancy: Results of a survey at a Turkish women's hospital in 1,020 patients

Summary We aimed to investigate the level of knowledge about the effects of cigarette smoking and status before and during pregnancy. The study was performed on 1,020 pregnant women who attended the clinic for a routine visit. The questionnaire consisting of questions about sociodemographic data, smoking habits and knowledge about harmful effects of smoking on fetus (miscarriage, intrauterine growth retardation, pre-term birth, fetal mortality-morbidity, postpartum infant death, pre-term premature rupture of membranes, lung disease, attention deficit) was administered. Data were analysed by SPSS 10.0 using χ2-test and binary regression analysis. Mean age was 26.3 years. Smoking rates before and after pregnancy were 34.7% and 14%, respectively. Passive smoking was seen in 69.2%. The number of cigarettes smoked before pregnancy had a significant impact on continuation of smoking during pregnancy [OR (95% CI) 29.94 (12.88–69.64)]. For passive smoking at home for a young age [OR (95% CI) = 1.33 (1.01–1.76)] had a positive impact and university education [OR (95% CI) = 0.40 (0.24–0.67)] had a negative impact. Most pregnant women (97.5%) knew smoking was harmful. Awareness of intrauterine fetal death as a harmful effect was the single most important factor associated with quitting active and passive smoking. Despite some level of knowledge of pregnant women regarding adverse effects of smoking, there is a strong need for education on quitting smoking during pregnancy. Prevention of passive smoking should have the highest priority.

Gestational Diabetes and Gestational Impaired Glucose Tolerance in 1653 Teenage Pregnancies: Prevalence, Risk Factors and Pregnancy Outcomes

STUDY OBJECTIVE The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) in adolescent pregnancies, associated risk factors, and pregnancy complications. DESIGN Retrospective study. SETTINGS Community-based teaching hospital. PARTICIPANTS Results of 1653 pregnant women age ≤ 19 years in 2005-2007 were reviewed. INTERVENTION All pregnant women screened with 50-g glucose challenge test (GCT) and patients with a GCT result ≥ 140 mg/dl underwent a 3-hour 100-g oral glucose tolerance test (OGTT). MAIN OUTCOME MEASURES GDM was diagnosed with at least two abnormal results and GIGT was diagnosed with one abnormal result. GDM and GIGT cases were evaluated for the presence of any associated risk factors and effects of presence of risk factors on pregnancy outcomes. RESULTS The prevalence of GDM was 0.85% (95% CI, 0.41-1.29), GIGT was 0.5% (95% CI, 0.15-0.81) and GDM+GIGT was 1.35% (95% CI, 0.78-1.88) by Carpenter and Coustan criteria. 68% of patients had at least one of the risk factors including body mass index ≥ 25, family history of diabetes and polycystic ovary syndrome (PCOS). Only 9.1% (n = 2) of them required insulin for glucose regulation during pregnancy with 9.1% (n = 2) macrosomia rate. All patients were primiparous and cesarean delivery rate was 27.3% (n = 6). We could not find any effect of presence of risk factors on pregnancy outcomes in GDM and GIGT cases. CONCLUSION We demonstrated that GDM and GIGT are strongly associated with high BMI before pregnancy, PCOS, and family history of diabetes. Since GDM is a state of prediabetes, it is important to diagnose in adolescent pregnancies considering their life expectancy to take preventive measures to avoid diabetes mellitus.

Glycosylated hemoglobin level in the second trimester predicts birth weight and amniotic fluid volume in non-diabetic pregnancies with abnormal screening test

Objective. To investigate relationship between glycemic control in first half of pregnancy by measuring mid-pregnancy HbA1c and neonatal birth weight and amniotic fluid volume. Methods. We prospectively enrolled 220 pregnant women who received oral glucose tolerance test (OGTT) after positive gestational diabetes mellitus screening. We included 102 women with normal OGTT results into final analysis. We measured birth weight and amniotic fluid index (AFI) at 32–34 weeks. Results. Mean birth weight was 3313 ± 426 g, and 15.7% of neonates were classified as large-for-gestational age (LGA). Mean Hb1Ac was 4.96 ± 0.28%. Median AFI was 145 mm, and polyhydramnios rate was 2.9%. Birth weight was positively correlated with HbA1c level (r = 0.373, p < 0.001) and pre-pregnancy body mass index (BMI; r = 0.351, p < 0.001). Linear regression analysis showed that HbA1c and pre-pregnancy BMI were positive independent determinants of neonatal birth weight, and HbA1c was positive independent determinant of AFI. Receiver operating characeristics curve identified HbA1c level of 4.99 as optimal threshold for prediction of LGA with 93.8% sensitivity, 61.6% specificity and positive likelihood ratio (+LR) of 2.45 and pre-pregnancy BMI value of 25.2 as optimal threshold for prediction of LGA with 81.3% sensitivity, 57% specificity and +LR of 1.9. Conclusion. In non-diabetic pregnant women with abnormal screening test, mid-pregnancy HbA1c level and pre-pregnacy BMI may predict neonatal birth weight. AFI in 32–34 weeks of gestation is related with mid-pregnacy HbA1c level.