Zehra Neşe Kavak

The potential of 4D sonography in the assessment of fetal neurobehavior - multicentric study in high-risk pregnancies

Abstract Objective: An evolving challenge for obstetrician is to better define normal and abnormal fetal neurological function in utero in order to better predict antenatally which fetuses are at risk for adverse neurological outcome. Patients and methods: Prenatal neurological assessment in high-risk fetuses using four-dimensional ultrasound applying the recently developed Kurjak antenatal neurodevelopmental test (KANET). Postnatal neurological assessment was performed using Amiel Tisons neurological assessment at term (ATNAT) for all live-borns and general movement (GM) assessment for those with borderline and abnormal ATNAT. Results: Inclusion criteria were met by 288 pregnant women in four centers of whom 266 gave birth to a live-born baby. It was revealed that 234 fetuses were neurologically normal, 7 abnormal and 25 borderline. Out of 7 abnormal fetuses ATNAT was borderline in 5 and abnormal in 2, whereas GM assessment was abnormal in 5 and definitely abnormal in 2. Out of 25 KANET borderline fetuses, ATNAT was normal in 7, borderline in 17 and abnormal in 1, whereas the GM assessment was as follows: normal optimal in 4, normal suboptimal in 20, and abnormal in 1. In summary, out of 32 borderline and abnormal fetuses ATNAT was normal in 7, borderline in 22 and abnormal in 3; GM assessment was normal optimal in 4, normal suboptimal in 20, abnormal in 6 and definitely abnormal in 2. Conclusion: The sonographic test requires further studies before being recommended for wider clinical practice.

Screening for pre-eclampsia by using maternal serum inhibin A, activin A, human chorionic gonadotropin, unconjugated estriol, and alpha-fetoprotein levels and uterine artery Doppler in the second trimester of pregnancy.

Aims:  To analyse the predictive power of maternal serum inhibin A, activin A, human chorionic gonadotropin (hCG), unconjugated estriol (uE3), alpha‐fetoprotein (AFP) levels and uterine artery Doppler in the second trimester of pregnancy in screening for pre‐eclampsia.

Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section: A prospective randomized study

OBJECTIVE To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries. METHODS Pregnant women admitted to our hospital from January 1999 to July 2000, for whom elective repeat cesareans were planned after 37 weeks gestation, were allocated randomly after their informed consent to spinal anesthesia or general anesthesia. Maternal age, gestational age, birth weight, Apgars score, hospital stay duration, and duration of cesarean section time were all noted. The rate of the neonatal respiratory depression, perinatal asphyxia, and admittance to the neonatal intensive care unit of the infants were documented. We also studied arterial samples withdrawn from the cord for the pH, bicarbonate, PaO(2) (oxygen pressure, arterial), and PaCO(2) (carbon dioxide pressure, arterial). The serum levels of creatine kinase with myocardial-specific isoform, aspartate aminotransferase, alanine aminotransferase, and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia (and of myocardial damage). Statistical analyses was performed with the use of an unpaired Students t-test, Chi-square test, and a power calculation was done. RESULTS From the randomly selected patients, we had 38 (45.2%) infants for general anesthesia and 46 (54.8%) for spinal anesthesia. None of our primary endpoints favored any of the study groups, and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia (P>0.05). The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress (P>0.05). CONCLUSION Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries. We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants.

Differential Diagnosis of Smooth Muscle Tumors Utilizing p53, pTEN and Ki-67 Expression with Estrogen and Progesterone Receptors

Background/Aim: To investigate the expression and value for diagnosis of the genes, p53 and pTEN, the protein, Ki-67, and the receptors, estrogen and progesterone, in differentiating smooth muscle tumors of the uterus. Material and Method: Seventeen samples of leiomyosarcoma, 2 smooth muscle tumors with uncertain malignant potential (STUMP), 9 atypical myomas and 15 leiomyomas were stained immunohistochemically. The χ2 test was used for the statistical analysis of the data. Results: The malignant side of the spectrum was strongly stained for Ki-67 and p53 while uniformly decreasing toward the benign tumors. The results were found to be statistically significant (p < 0.0001). The staining for progesterone receptor was also statistically significant, but the tumors that were considered benign, such as leiomyoma and atypical myoma, were the ones strongly stained (p = 0.005). The expression of estrogen receptor was significant in these tumors, but the p value was very close to the cut-off value (p = 0.07). As the degree of differentiation of the tumor increased, the trend showed stronger staining for estrogen receptor. However, no difference was detected in the staining properties of the tumors for pTEN (p = 0.2457). Conclusion: The expression of Ki-67, p53 and progesterone receptors is promising in immunodifferentiation of smooth muscle tumors of the uterus with malignant potential.

The influence of prenatal counselling on postpartum contraceptive choice.

This study tested the hypothesis that individual counselling in the third trimester would increase postpartum contraceptive use to a greater extent than only providing an educational leaflet. A total of 180 third trimester pregnant women of mean age 28.3 years who were attending Marmara University Hospital for prenatal care were enrolled. One-third were randomly allocated to receive prenatal contraceptive counselling and the remaining two-thirds (control group) received an educational leaflet. Participants were followed-up at 6–9 months postpartum. The majority of subjects (91.5%) wanted to use contraception after delivery but 26.7% did not know which method to use. At follow-up, 79.6% of all women had begun a postpartum contraceptive regime and 68.7% were using a modern contraceptive method. Overall, there was no statistically significant difference in postpartum contraception use between the control and intervention groups in this study population. It is, therefore, concluded that prenatal counselling was not superior to educational leaflets for increasing the use of effective and modern postpartum contraception.

Placental volume and vascularization flow indices by 3D power Doppler US using VOCAL technique and correlation with IGF-1, free beta-hCG, PAPP-A, and uterine artery Doppler at 11–14 weeks of pregnancy

Abstract Aims: The purpose of this study was to investigate correlations between first trimester placental volume (PV) and blood flow indexes (FIs), bilateral uterine artery pulsatility indexes, notching, and biochemical parameters: pregnancy-associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (f-β-hCG), and insulin-like growth factor-1 (IGF-1) to predict the high-risk pregnancies in the first trimester. Methods: We prospectively examined 310 patients at 11–14 weeks of pregnancy using transabdominal 3D gray scale and power Doppler ultrasound for assessing PV, vascularization index, FI, and vascularization FI (VFI). The acquired volumes were analyzed using VOCAL™ imaging software. The results were correlated with biochemical parameters. Results: We found significant correlations between PV and biochemical parameters, and between placental blood flow studies and other parameters. Finally, PV/crown-rump length so called the placental quotient is also related to both PAPP-A and VFI. Conclusions: Placental volumetry, uterine artery Doppler studies, blood flow calculations and biochemical parameters, such as f-β-hCG, PAPP-A, and IGF-1 could be important in the early and rapid diagnosis of high-risk pregnancies. Thus, they may be useful in first trimester prediction of fetal growth restriction presenting with alterations in PV and vascularity.

The efficacy of first-trimester PAPP-A and free βhCG levels for predicting adverse pregnancy outcome

Abstract Objective: To determine whether first-trimester measurements of maternal serum PAPP-A and free βhCG levels were associated with adverse pregnancy outcomes. Study Design: First trimester maternal serum free βhCG and PAPP-A were measured in 490 singleton pregnancies. Pregnancies were followed by the fetal-maternal unit, and predictive efficacy of these markers for small for gestational age (SGA) babies, gestational diabetes mellitus and hypertensive disorders were analyzed by cut-off values determined by using a ROC analysis, and also, by using the fifth percentile as the cut-off value. Results: The sensitivities for PAPP-A in predicting pregnancies with a SGA baby and those complicated by a hypertensive disorder were 49% and 73%, respectively, when optimal cut-off values were used. Specificities were 76% and 65%, respectively. Serum free βhCG had no predictive value for individual pregnancy outcomes. Conclusion: Efficacy of first trimester maternal serum markers in predicting adverse pregnancy outcome is low. Even after optimization of cut-off values, these markers do not appear to be clinically acceptable as an effective tool for screening for adverse pregnancy outcomes.

Hydatid Cyst of the Uterus

BACKGROUND: Hydatidosis is a common zoonosis that affects a large number of humans and animals, especially in poorly developed countries. The infesting parasite has four forms named Echinococcus granulosis, E. multilocularis, E. vogeli and E. oligarthrus (very rare in humans). The most frequently involved organs are liver followed by the lung. The involvement of the genital tract is rare and the occurrence in the uterus is an extreme rarity. We report a case of hydatid cyst in the uterus. CASE: A 70-year-old female with a history of hydatid cysts of the liver, was admitted to hospital after complaining of low abdominal pains. On physical and gynecological examinations, no pathological finding was detected. However, the uterus was significantly large for a postmenopausal patient. Transvaginal sonography (TS) revealed a cystic mass in the uterus with a size of 7 x 6 cm. After further examinations a subtotal hysterectomy was performed. Microscopic examination showed scolices of Echinococcus granulosis. CONCLUSION: Hydatid cysts in the genital tract are rare and the occurrence in the uterus is an extreme rarity. Differentiation between hydatid cyst and malignant disease of the related organ is difficult. To avoid misdiagnosis, a careful examination of pelvic masses should be carried out in endemic areas for detection of hydatid cysts.

Effect of smoking on pregnancy-associated plasma protein A, free β-human chorionic gonadotropin, and nuchal translucency in the first trimester of pregnancy

Data were collected from 1275 pregnant Turkish women screened prospectively for chromosomal anomalies to determine whether first-trimester levels of maternal serum pregnancy-associated plasma protein A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) and the thickness of nuchal translucency are affected by smoking and other covariables. Only normal singleton pregnancies were included. After weight correction, comparisons were made between smokers and nonsmokers. Mean values of PAPP-A and β-hCG were reduced in women who smoked 5 or more cigarettes a day compared with nonsmokers. The median β-hCG level decreased significantly as gravidity and parity increased; no effect was noted on PAPP-A. Median PAPP-A and β-hCG levels tended to increase, but not significantly in women who had had 2 or more miscarriages. Smoking alters maternal levels of serum analytes, with the magnitude of the impact related to the number of cigarettes smoked per day. This effect can be detected in the first trimester of pregnancy.

Thoraco-Omphalopagus Conjoined Twins Detected at as Early as 9 Weeks of Gestation: Transvaginal Two-Dimensional Ultrasound, Color Doppler and Fetoplacental Doppler Velocity Waveform Findings

Here we report a case of conjoined twins that were diagnosed antenatally by routine two-dimensional transvaginal ultrasound examination at as early as the 9th week of gestational age. The fetuses were of the thoraco-omphalopagus type and were sharing the liver, as confirmed by color Doppler. There was a reversed flow in the single ductus venosus of the twins. Umbilical arterial and venous blood flow waveform did not show any abnormality for this gestational age. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins in the first trimester by transvaginal two-dimensional ultrasound and color Doppler examination. Although conjoined twins were described at first trimester before, fetoplacental Doppler waveform findings at this gestational age have been described very rarely. This case demonstrated the possibility of making an accurate diagnosis of conjoined twins and delineating the extent of organ sharing in the first trimester, and early diagnosis can help the parents with the option for pregnancy termination. The importance of expert early vaginal sonography and color Doppler findings is emphasized.