Zarif Yilmaz

Reproductive outcome of women with unicornuate uterus

This study was undertaken to examine the reproductive impact of unicornuate uterine abnormalities cases in a group of 571 women with a uterine anomaly. Hospital records of 1784 patients who presented to the infertility outpatient clinic with infertility, recurrent pregnancy loss, pain or acute abdomen during the study period between January 1991 and January 2001, were reviewed retrospectively. The reproductive performance of women with unicornuate uterus was poor, with a live birth rate of only 29.2%, prematurity rate of 44%, miscarriage rate of 29%, and an ectopic pregnancy rate of 4%.

A retrospective study on the reproductive outcome of the septate uterus corrected by hysteroscopic metroplasty.

Septate uterus one of the most common of Mullerian duct anomalies is most effectively corrected by hysteroscopic metroplasty which improves the subsequent reproductive outcome. In this background this study evaluates the reproductive outcome of 361 with septate uterus who underwent hysteroscopic metroplasty between 1990-2000 at the Zekai Tahir Burak Womens Health Education and Research Hospital. Overall the results indicated a pregnancy rate of 75% (135 patient) in the secondary was significantly higher than the pregnancy rate of 25% (45 patients) in the primary fertility group. Furthermore findings revealed that 29 (16%) pregnancies resulted in spontaneous abortion 34 (18.8%) ended in preterm birth and the remaining 117 (57.2%) reached term. 18 (52.9%) of the pre-term babies were able to survive and overall there were 135 (75%) live births. In conclusion hysteroscopic metroplasty improves the reproductive performance of septate uterus significantly especially in patients with recurrent pregnancy loss and should be considered a valuable corrective approach for such patients.

Fetal survival despite unrecognized uterine rupture resulting from previous unknown corporeal scar.

Abstract Cesarean scar rupture of a gravid uterus with unknown corporeal scar is common. Our case was a 35 year woman, gravida 2, para 1 presented at 38 weeks gestation. She was admitted to our hospital for routine follow up. She had no signs or symptoms of labor. However eight hours after the initial examination, she came back to hospital with the signs of shock and acute abdomen. Immediately she was referred to surgery. Intraoperatively a complete rupture of the classical corporeal incision was observed, but the fetus was enclosed within the anterior lying plasenta. The fetus was delivered with one minute apgar score 3, and five minute apgar score 8. According to this case, we conclude that spontaneous uterine rupture of the classical uterine scar can be observed even without uterine contractions. So women with the possibility of previous classical uterine incision should be delivered once fetal maturity is documented.

Reply: Maternal Suicide after Pregnancies in a Rudimentary Horn

Reading the article of Akar et al. in the recent journal, reminded me of a fascinating case of mine some years ago, relevant to this paper, which may be of interest to the Journal readership. An unusual case of a foetal death in-utero in the unconnected rudimentary horn of a congenitally abnormal uterus was seen. Conjecture was raised as to how the pregnancy had arrived at this site and it was postulated that transperitoneal fertilisation and implantation had occurred. Due to a poorly interpreted ultrasound at that time and the patient’s refusal to allow a diagnostic laparoscopy/hysteroscopy, we were unaware of her uterine abnormality. Unsuccessful expulsion of the dead conceptus was attempted conservatively, firstly by induction with prostaglandins in association with oxytocics intravenously and subsequently by a repeated course of vaginal prostaglandin pessaries. Ultimately I submitted this patient to laparotomy for diagnosis of her uterus bicornis unicollis and management by excision of the pregnant horn. This was followed by an easy reconstitution of the remaining hemi-neo-uterus with its associated tube and ovary, associated with surgical re-attachment of the contra-lateral ovary to the uterine body. At that time advice was given that apparent insensitivity to prostaglandin/oxytocic stimulation should alert the gynaecologist to the possibility of uterine abnormality allowing him to desist and avoid the risk of uterine rupture and associated dangers. On three further occasions this woman successfully fell pregnant again but regrettably miscarried each time. Thereafter, however, her hemi-uterus presumably ‘stretched’ enough to allow a further viable pregnancy to proceed to almost term. At 37/2 weeks gestation I undertook an elective caesarean section for a footling breech presentation delivering a healthy male infant weighing 2800 g to a delighted couple who after multiple manipulations, had finally succeeded in achieving a much desired family. Eight months into her puerperium her family doctor notified me that Mother quite unpredictably had committed suicide by hanging herself in the living room at home. After all the endeavours on her behalf to achieve a healthy pregnancy this intelligent Grammar school teacher was found dead by her own hand. Presumably this was due to her inability to cope mentally with the various gynaecological procedures over many years on her behalf to achieve motherhood, and an undiagnosed postnatal depression!

Fetal survival despite unrecognized uterine rupture resulting from previous unknown corporeal scar

praevia, grand multparity, obesity, gross varicose veins) and to asses the effectiveness of AFC transfusion in their prevention. Study Methods: In 56 patients with above mentioned risk factors coagulation parameters (fibrinogen, platelet count, APTT, thrombin clotting time, and antithrombin III activity (AT III) were measured during CS and the first 5 postoperative days. This group was compared with 58 patients who met the same criteria for hemorrhage and thromboembolism. In this group (II) in the III trimester of pregnancy 600-900 ml of AFFP was collected by means of plasmapheresis and used intaoperatively to restore coagulation inhibitor AT III and to stop depletion of clotting factors. Results: In the first group haemostasiological evidences of consumption coagulopathy detected at the end of CS (reduction of fibrinogen from 4.2eO.23 g/l to 2.7eO.21 g/l and platelets from 240*7.6.10 /l to 194*6.4.10 /l) were preceded by intraoperative reduction in AT III activity (73.5*1.2%). In the second group, after intraoperative transfusion of AFFP and size of AT III level to 86.4*2.2% (~~0.05) the consumption of coagulation factors was stopped (fibrinogen 3.84eO.36 g/l (p<O.O5), platelets 216*9.1.10/l (p<O.O5). AT III activity >80% in these patients was detected during all the first 5 postoperative days, while in the fist group AT III returned to normal values only on the fifth day after operation. Conclusion: Intraoperative transfusion of AFFP increases anticoagulant activity, prevents coagulation disturbances during CS and be effectively used to reduce the incidence of hemorrhages and thromboembolic complications in patients with high risk factors delivered by CS.