CA 125 and other tumor markers in uterine leiomyomas and their association with lesion characteristics.

The aim of this study was to investigate the factors associated with serum levels of several tumor markers in a group of patients operated for uterine myoma. One hundred thirty-seven female patients operated for uterine myoma were included. Serum samples were examined for CA 125, CA 19-9, CA 15-3, carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) levels as part of routine workup. Pathological and morphological characteristics of the patients were retrieved from medical records. The mean age was 46.7 ± 8.8 years (range, 22-85 y). Abnormally high levels of CA 125, CA 19-9, CA 15-3, CEA, and AFP were found in 19.7%, 6.6%, 5.1%, 3.7%, and 1.5% of the patients, respectively. Patients with additional adenomyosis and patients with at least one large myoma (≥ 5 cm diameter) had significantly higher levels of CA 125. Multivariate analysis identified coexistence of adenomyosis (OR 7.7 [95% CI, 2.6-23.0], p < 0.001) and presence of at least one large myoma (OR 5.6 [1.4-22.8], p = 0.016) as independent predictors of abnormally high CA 125 levels. CA 125 levels are affected by the tumor size and coexistence of adenomyosis in uterine leiomyomas. Indirect mechanisms caused by large myoma size such as peritoneal irritation may be responsible for CA 125 elevations.

A rare case of postmenopausal immature teratoma with a recurrent grave course.

Immature teratoma is quite uncommon older women, particular in postmenopausal period. Only a few cases of postmenopausal immature teratoma of the genital tract have been reported. This report describes a postmenopausal aggressive pelvic immature teratoma case with a grave course despite treatment. A 67-year-old woman being in menopause for the past 16 years was diagnosed with immature teratoma in the pelvic cavity. The mass was removed completely and hysterectomy plus bilateral salpingo-oophorectomy was done. Histopathological diagnosis was grade 2 immature teratoma. The patient had a grave course with recurrences despite therapy and died within one year after initial diagnosis. In teratomas diagnosed over 45 years of age, the possibility of malignant teratoma should also be borne in mind.

Comparison of transvaginal ultrasonography and hysteroscopy in the diagnosis of uterine pathologies.

A thorough evaluation of the uterine cavity is frequently required in gynecology practice. The aim of this study was to compare the diagnostic values of transvaginal ultrasound examination and hysteroscopy in detecting uterine abnormalities in a group of patients within a range of menopausal status and symptomatology. This study included 285 patients admitted with complaints of abnormal uterine bleeding, postmenopausal bleeding, lower abdominal pain, abnormal vaginal discharge or for a routine gynecological examination. All patients had available transvaginal ultrasonography and hysteroscopy data for evaluation. A biopsy was obtained from all patients during the hysteroscopy session. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio were calculated for both methods and compared, considering the histopathological diagnosis as the gold standard. The mean age of the patients was 49.5±12.9 years (range, 24-89 y). Majority of the patients admitted for abnormal uterine bleeding (n=198, 69.4%). For the diagnosis of polyps of any size, hysteroscopy had better sensitivity (p<0.001), however, specificities did not differ (p=1.0). On the other hand, hysteroscopy did not have a sensitivity advantage over TVU in diagnosing polyps greater than 1 cm (p=0.077), although this time hysteroscopy had better specificity (p<0.001). Combined approach did not offer diagnostic advantage for any of the specific pathologies. Although TVU represents a practical approach for the initial evaluation of uterine pathologies, hysteroscopy seems to offer better diagnostic value for uterine pathologies in general, and uterine polyps in particular.

The assessment of the relationship between amniotic fluid matrix metalloproteinase-9 and zinc levels with adverse obstetric outcomes.

OBJECTIVE: To examine the relationship between the amniotic fluid MMP-9 and zinc levels during 16-19th gestational weeks and perinatal outcomes. METHOD: One hundred and seventeen singleton pregnancies that underwent genetic amniocentesis from January 2005 through November 2009 were evaluated. Subjects were divided into two main groups: a control group (group 1) (n: 74), and an adverse obstetric outcomes group (group 2) (n: 43). Group 2 consisted of the following: preterm birth group, gestational hypertension and preeclampsia group, gestational diabetes group, fetal growth restriction group, macrosomia group, and pregnancy loss group. MMP-9 and zinc (Zn) values in the amniocentesis materials sampled between the 16th and 19th gestational weeks were analyzed retrospectively in terms of perinatal outcomes. Any significant difference among the groups was assessed by unpaired samples t test and the Mann-Whitney U test. Statistical significance was defined as p < 0.05. RESULTS: A comparison among groups showed no significant difference in terms of Zn results between the group 1 and 2 (p = 0.879). MMP-9 levels were significantly lower in both the preterm birth group (p = 0.043) and group 1 (p = 0.015). CONCLUSION: We found that the amniotic fluid MMP-9 levels of patients who delivered preterm were significantly lower between the 16th and 19th gestational weeks.

Effect of an amniotic sheet on pregnancy outcomes.

OBJECTIVES: Our aim was to evaluate whether the presence of an amniotic sheet affects obstetric and neonatal outcomes. METHODS: All singleton pregnant women with and without a sonographic diagnosis of an amniotic sheet between the 16th and 24th weeks of pregnancy were retrospectively identified. Two women without an amniotic sheet were randomly selected from the similar stratified periods as a control group for each case. The demographic characteristics and obstetric and perinatal outcomes were compared between the groups. Multivariable logistic regression was also performed for potential confounding factors. In addition, the subsequent pregnancies of 12 women with an amniotic sheet were followed during the antenatal and postnatal periods. RESULTS: The prevalence of an amniotic sheet was 1.13%. The risk factors for an amniotic sheet were primiparity, previous normal vaginal delivery, previous dilation and curettage, and previous abortions. When the groups were compared in terms of maternal and neonatal outcomes, the rates of a nuchal cord at birth, breech birth, birth weight of less than 2500 g, preterm delivery (<37 weeks), and neonatal intensive care unit admission were higher in the amniotic sheet group than the control group. There were 2 intrauterine deaths in the amniotic sheet group. In addition, an amniotic sheet was not observed again in any of the subsequent pregnancies of the 12 cases from the amniotic sheet group, and these pregnancies eventuated uneventfully. CONCLUSIONS: An amniotic sheet is associated with an increase in poor obstetric outcomes. Therefore, close monitoring of pregnancies after diagnosis is required.

The effect of placental removal method on perioperative hemorrhage at cesarean delivery; a randomized clinical trial.

PURPOSE: The aim of this prospective randomized clinical study is to compare whether the removal methods of placenta during cesarean section have an impact on perioperative hemorrhage. METHODS: One hundred women with singleton term pregnancies undergoing elective cesarean section through lower segment transverse incision under general anesthesia were included in this study. They were randomly allocated to two groups according to the type of removal of the placenta from the uterus after childbirth; manually or spontaneously. The main outcome measures were change in hemoglobin levels after cesarean section. The secondary outcomes were operative time, required transfusions and postcesarean endometritis. RESULTS: Fifty patients were randomized to the manual removal group and 50 to the spontaneous group. The demographic characteristics of the two groups were similar. There were no difference in terms of change in hemoglobin levels after cesarean section between two groups (1.6 ± 1.0 and 1.5 ± 1.0, respectively; P = 0.711). In addition, none of the patients required blood transfusion and showed postpartum infections. CONCLUSION: There is not an association between the method of removal of the placenta and postpartum blood loss in cesarean section deliveries.

Evaluation of neonatal outcomes in elective repeat cesarean delivery at term according to weeks of gestation.

AIM: Our aim is to evaluate the association between gestational age at delivery and neonatal outcomes in elective cesarean delivery. MATERIAL AND METHODS: A total of 1784 viable singleton pregnancies that were delivered by elective caesarean section at term were included in the study. All pregnancies were categorized according to the number of completed weeks of gestation (37(+0-6) , 38(+0-6) , 39(+0-6) and ≥40(+0) weeks). In this study, the patient groups compared in terms of demographic characteristics and neonatal outcomes. RESULTS: The rates of the neonatal intensive care unit admission were 8.7%. When maternal and neonatal characteristics were statistically analyzed, the incidence of advanced maternal age and previous cesarean delivery increased as gestational age at delivery decreased; the incidence of nuchal cord and delivering a baby of ≥4000 g at birth increased as gestational age at delivery increased. As compared with deliveries at 39 weeks, cesarean delivery at 37 weeks of gestation had significantly higher risk, including that of neonatal intensive care unit admission, transient tachypnea of the newborn after delivery and O(2) support. There was one perinatal death observed in the study. CONCLUSIONS: According to the results of our study, compared to elective cesarean delivery after 37 weeks of gestation, elective cesarean delivery at 37 weeks of gestation was associated with a statistically significant increase in neonatal mortality. Therefore, elective cesarean delivery should not be performed at 37 weeks of gestation and 39 weeks of gestation appears to be the ideal timing for elective cesarean delivery.

A comparison of pregnant subgroups with positive 50-gram glucose challenge test results to those with negative results in terms of obstetric and perinatal outcomes.

AIM: To compare the pregnant subgroups with positive 50-gram glucose challenge test results to those with negative results in terms of obstetric and perinatal outcomes. METHODS: A total number of 977 pregnant women were included in the study. A glucose challenge test was performed for all pregnant women. Subsequently, 3 hours 100 gram oral glucose tolerance test was performed for the patients who had a positive test. According to 50-gram glucose challenge test 1st hour glucose values, the patients were categorized into 5 subgroups (less 140, 140-159, 160-179, 180-199 and ≥200). Also, the patients, whose 3 hours 100 gram oral glucose tolerance tests were positive, as well as those diagnosed with impaired glucose tolerance, were included in Group 5. All the groups were compared in terms of obstetric and perinatal outcomes. RESULTS: Cut-off scores of 50-gram glucose challenge test were found to be 153.5 mg/dl. It was observed that the glycemic values increased as the mean of delivery week decreased. The differences between all groups were found to be statistically significant with regard to macrosomia, large for gestational age, presentation anomalies, polyhydramnios, ablatio placentae, preeclampsia and gestational hypertension. Increase in the rate ratio was observed for the glycemic values, they got higher. The results showed statistically significant differences between all groups in terms of neonatal hospitalizations after birth and observation rates. CONCLUSION: The patients with a 50-gram glucose challenge test 1st hour glucose values of 180 mg/dl or higher are associated with poor perinatal and fetal outcomes.

Is adenomyosis associated with the risk of endometrial cancer?

AIM: To evaluate an association of adenomyosis with endometrial cancer and to determine the frequency of adenomyosis at hysterectomy specimens. METHODS: This study was carried out retrospectively on pathologic specimens of hysterectomies. A total of 472 women in the period 2007-2011 enrolled to the study. All pathologies seen in hysterectomy specimens were noted. The frequency of adenomyosis and the accompanying pathologies were determined. These women were categorized into two groups according to the presence of adenomyosis. The incidence of adenomyosis was analyzed together with the endometrial cancer. RESULTS: The incidence of adenomyosis was 20.8% at hysterectomy specimens. There was no statistically significant difference between the mean age of the two groups (p = 0.069). There were 98 cases with adenomyosis and the only pathologic finding was adenomyosis, in 28 (28.5%) cases. The most common accompanying pathologies with adenomyosis were uterine myomas in 51 (52%), uterine polyps in 16 (16.3%) and endometrial carcinomas in 11 (11.2%) cases. However, statistically significant association of the presence of adenomyosis with uterine myoma (p = 0.227) and endometrial polyps (p = 0.997) and endometrial carcinoma (p = 0.771) was not found. CONCLUSION: In hysterectomy specimens, no statistically significant difference was determined between the groups with and without adenomyosis in terms of co-occurrence with endometrial carcinoma.

Serum vitamin B12 and homocysteine levels in pregnant women with neural tube defect.

OBJECTIVE: The aim of the study is to investigate the importance of serum vitamin B12 levels in pregnant women with foetal neural tube defect (NTD). STUDY DESIGN: This study consists of 31 pregnant women having fetuses with NTD. The pregnant women in the study group were selected among cases with normal folate levels. Serum vitamin B12 levels were investigated. Additionally, complete blood count, serum iron level, iron binding capacity, ferritin, folate, free T(3), free T(4), thyroid stimulating hormone and plasma homocysteine levels were measured. Control group consisted of 32 pregnant women who did not have a history of NTD in previous pregnancies and did not have fetuses with NTD in present pregnancy. NTD was diagnosed between 14th and 20th gestational age. The mean gestational age of members of control group was the same as those of NTD group. RESULTS: There was no statistically significant difference between pregnants with NTD and control group according to number of cases with vitamin B12 deficiency. CONCLUSION: It seems that vitamin B12 deficiency does not play a causative role in the development of foetal NTD. Monitoring maternal homocystein levels might be important in understanding the aetiologies of foetal NTD.

Prenatal diagnosis of vertebral deformities associated with pentalogy of Cantrell: the role of three-dimensional sonography?

Pentalogy of Cantrell was diagnosed in a fetus at 14 weeks of gestation, on routine two-dimensional sonographic examination with Doppler imaging, which revealed a midline supraumbilical abdominal wall defect including herniated liver, an ectopia cordis without intracardiac anomalies, and a large omphalocele containing intestines. Although left unilateral club foot deformity was also detected as an associated anomaly in the same examination, severe lumbar lordoscoliosis was only detected by using three-dimensional sonography because of the spatial configuration of the deformity. After termination of the pregnancy, postnatal inspection of the fetus confirmed the diagnosis of pentalogy of Cantrell associated with skeletal deformities and revealed low implant ears as an additional finding. Although two-dimensional sonography with Doppler imaging is sufficient to diagnose pentalogy of Cantrell, it may fail to show the complex vertebral deformities and three-dimensional sonography may assist in visualizing the defect accurately.

The outcome of adding peripheral neuromodulation (Stoller afferent neuro-stimulation) to anti-muscarinic therapy in women with severe overactive bladder.

OBJECTIVE: Anti-muscarinic treatment alone and peripheral neuromodulation with concomitant anti-muscarinic treatment were compared in patients with severe overactive bladder. METHODS: In this prospective study, 40 women with severe overactive bladder according to the 7-day voiding diary without any prior treatment completed the Incontinence Impact Questionnaire (IIQ-7) and were randomised into anti-muscarinic-alone and combination treatment groups. Twenty women received daily 4 mgs of tolterodine orally and in 20 women Stoller afferent neuro-stimulation (SANS) therapy was performed concomitantly for 12 weeks to the same anti-muscarinic regimen. After 12 weeks of therapy, two of the patients drop out of the study and remaining patients filled out the IIQ-7 questionnaire and the 7-day voiding diary again. Pretreatment and post-treatment QoL scores and the 7-day voiding diaries were compared. Mann-Whitney U, Wilcoxon and two sided significance tests were used. RESULTS: Thirty-eight women fulfilling the criteria were included in the study. Severity of overactive bladder symptoms decreased significantly in both treatment groups. However, the decrease in combination treatment group was more significant than the anti-muscarinic-alone group. Adverse events were similar between the two groups. CONCLUSION: Combining SANS and anti-muscarinic therapy resulted in significantly better clinical outcomes and IIQ-7 scores as compared with anti-muscarinic treatment alone in patients with severe overactive bladder.

Is prenatal volumetric evaluation of aneurysm of the vein of Galen important in the prediction of adverse fetal outcome?

Aneurysm of the vein of Galen is a rare congenital vascular malformation of the central nervous system. There are controversies in the literature regarding the possible prognostic value of aneurysmal volume estimation with 3-dimensional US for the prediction of fetal outcome. In this report, we present a case of prenatally diagnosed large aneurysm of the vein of Galen complicated by heart failure in a fetus. The volume of the malformation was calculated as 17.8 cm(3) and the fetal outcome was poor.

Longitudinal study of platelet size changes in gestation and predictive power of elevated MPV in development of pre-eclampsia.

OBJECTIVES: The aim of this cohort is to investigate whether any haematologic changes detectable by simple complete blood count (CBC) precede pre-eclampsia development and the diagnostic value of these markers in clinical practice for prediction of pre-eclampsia. METHODS: All pregnant women, in the first trimester, attending to GATA Haydarpasa Teaching Hospital Obstetric Outpatient Clinic for routine obstetric care were enrolled. Routine obstetric care consisted of monthly visits until 32nd week, bimonthly visits between 32nd and 36th week, and weekly thereafter. According to the study, protocol CBC was taken from women at each visit and recorded. After delivery, outcome data were obtained. RESULTS: A total of 1336 women were included into the statistical analysis and 107 (8%) of them developed pre-eclampsia. Parameters of CBC were similar between groups other than mean platelet volume (MPV) values. MPV values of pre-eclamptic women were significantly higher than normotensive counterparts from 24th gestational week up to gestational week at birth. In pre-eclamptic group, mean gestational age of diagnosis was 33.8 weeks and significant MPV increase was detected to precede the diagnosis by approximately 4.6 weeks (range 2.8-5.9 weeks). CONCLUSIONS: Our study provides evidence that MPV gradually increases in pregnant women affected by pre-eclampsia compared to women with normal pregnancies.

First trimester screening for Down syndrome in rhesus negative women.

OBJECTIVES: To explore the effect of maternal rhesus status on first-trimester screening markers for Down syndrome. METHODS: We accessed a database of singleton pregnancies undergoing first-trimester genetic screen with maternal Rh status documented and pregnancy outcome information available. Excluded were cases of fetal chromosomal or structural abnormalities, or maternal systemic disease. Results of maternal serum pregnancy-associated plasma protein A (PAPP-A) and beta-human chorionic gonadotrophin (beta-hCG) adjusted for gestational age were compared between Rh-negative and Rh-positive women with p < 0.05 considered significant. RESULTS: Two thousand two hundred and two pregnancies fulfilled the study criteria, and 160 of them (7%) were Rh negative. Only free beta-hCG corrected multiples of the median (MoM) values were statistically increased in Rh-negative women (p < 0.009). Using a cut-off of 1:300, screen-positive rates of maternal serum biochemistry were not significantly different between Rh-negative and Rh-positive women (12.5 vs 10.4%, p = 0.41). CONCLUSION: The present study focused on measurements of beta-hCG and PAPP-A in the sera of women with Rh-negative blood group. Women with Rh-negative blood type have similar first-trimester serum PAPP-A MoM values as Rh-positive women, but significantly higher beta-hCG MoM values. However, there was no significant difference in the screen-positive rate for Down syndrome between the two groups.

Tension-free vaginal tape for surgical relief of intrinsic sphincter deficiency: results of 5-year follow-up.

STUDY OBJECTIVE: We evaluated effectiveness of tension-free vaginal tape application for surgical relief of intrinsic sphincter deficiency. DESIGN: A prospective study (Canadian Task Force classification II-3). SETTING: Tertiary center of medical faculty. PATIENTS: We studied 47 patients. INTERVENTIONS: Tension-free vaginal tape procedure, questionnaire form, stress test, cotton swab test, and functional bladder volume measurements. MEASUREMENTS AND MAIN RESULTS: Patients were grouped as intrinsic sphincter deficiency according to American College of Obstetricians and Gynecologists criteria. Operative results were documented at 6, 12, 36, and 60 months after the procedure by using a questionnaire form and objective tests of stress test, cotton swab test, and mean bladder functional volume measurement. At first visit 6 months after procedure, 70% (n = 35) of patients were completely satisfied, 9 (18%) had improved urine control, and 5 (10%) had no change in urine control. Results were: 72% (n = 36), 12% (n = 6), and 14 (n = 7%) at the end of the first year, and 66% (n = 33), 20% (n = 10), and 14% (n = 7) at the end of the third year, respectively. The fifth year's follow-up visit revealed 57.4% (n = 27 of 47) satisfaction, 17.02% (8 of 47) improved urine control, and 25.5% (12 of 47) no change in urine control. CONCLUSION: Tension-free vaginal tape procedure is a safe and effective technique for patients who have exclusively intrinsic sphincter deficiency. Long-term results will clarify the value of this procedure in comparison with classic antistress surgical techniques.

Aromatase inhibitors for infertility in polycystic ovary syndrome. The beginning or the end of a new era?

A meta-analysis of four trials showed significant advantage in pregnancy and delivery rates with aromatase inhibitors compared with CC in women with PCOS. A recent randomized trial demonstrated no clear benefit.

Overlapping repair in patients with anal sphincter injury.

OBJECTIVE: The aim of this study was to demonstrate the improvement of anal canal function after overlap sphincter repair and confirm that this treatment option is superior in patients with nonobstetric sphincter damage. SUBJECTS AND METHODS: From 1998 to 2003, 44 women who underwent overlapping sphincter repair were enrolled in this study. The women were allocated to one of two groups, obstetric trauma (n = 31) and nonobstetric (perineal) trauma (n = 13). Both groups were compared in terms of age, operation time, number of deliveries, hospital stay, need for analgesics, complication rate, pre- and postoperative outcomes of anal manometry and quality of life, using the fecal incontinence severity index and a questionnaire for fecal disorders. RESULTS: Anal canal length was significantly extended postoperatively in both groups compared to preoperative length. Eight-week postoperative resting and squeeze pressures were significantly higher than preoperative pressures in both patients with nonobstetric and obstetric sphincter injury. Although significant increase was seen in both groups, the mean postoperative resting and squeeze pressures at 1 year were rather high in patients with nonobstetric sphincter injury. At the end of a year of follow-up, overall satisfaction of the repair was about 82%. CONCLUSION: Overlap sphincter repair was feasible, although patient satisfaction was slightly less in the obstetric than in the nonobstetric trauma group. The improvement of anal function at 20- to 24-month follow-up is attributed to both high squeeze pressure and broad anal canal.

Efficacy of laparoscopically-assisted extracorporeal cystectomy in patients with ovarian endometrioma.

STUDY OBJECTIVE: To investigate the usefulness and effectiveness of the extracorporeal surgical technique in the treatment of endometriomas. DESIGN: Retrospective evaluation (Canadian Task Force Classification II-2). SETTING: Department of gynecology in a tertiary care faculty hospital and training hospital. PATIENTS: Of 89 patients with endometrioma, 53 had laparoscopic stripping, and 36 had laparoscopically-assisted extracorporeal cystectomy. INTERVENTIONS: Laparoscopic stripping and laparoscopically-assisted extracorporeal cystectomy were performed for the treatment of endometriomas diagnosed laparoscopically. MEASUREMENTS AND MAIN RESULTS: The size of the endometrioma diagnosed by the ultrasonographic examination was not statistically related to the severity of the endometriosis (p = .42). Conversion to extracorporeal technique was required in 17 of 58 cases with moderate endometriosis and 14 of 31 cases with severe endometriosis (p = .04). Operation time, visual analogue pain score, and hospitalization periods were similar between the 2 techniques. Among 53 specimens obtained with laparoscopic stripping, 29 (55%) had no ovarian tissue, and 24 (45%) had ovarian tissue with follicles. Of 36 specimens obtained with extracorporeal technique, 19 (52%) had no ovarian tissue, and 17 (48%) had ovarian tissue with follicles. Preservation of the ovarian tissue was not significantly different between both surgical techniques. CONCLUSIONS: Extracorporeal technique with laparoscopically-assisted minilaparotomy is a valuable alternative for laparoscopic stripping in selected cases.