Elastosonographic evaluation of endometrium in women using tamoxifen for breast cancer.

OBJECTIVES: A prospective case-control study was carried out to assess the value of elastosonography in identifying endometrial pathology in women using Tamoxifen (TAM) for breast cancer. MATERIALS AND METHODS: In total, 66 women using TAM for breast cancer were enrolled for the study with 61 premenopausal and 61 postmenopausal healthy controls. Ultrasonographic findings (strain ratio, endometrial thickness) were evaluated in regard to the duration of TAM usage, histopathological findings, and menopausal status. RESULTS: Patients with endometrial cancer (EC) and cystic endometrial hyperplasia (CEH) were found to have longer duration of TAM usage, increased endometrial thickness, and higher strain ratios compared with controls. A significant positive correlation was found between duration of TAM usage, endometrial thickness, and the strain ratios. Endometrial thickness and the strain ratios were significant predictors for groups under risk. Cutoff values for endometrial thickness, strain ratios, and duration of TAM usage were 12.55 mm, 2.46, and 18 months in premenopausal group and 7.75 mm, 7.70, and 32 months in postmenopausal group to predict risky population, respectively. CONCLUSION: Endometrial tissue strain ratio was found to be significantly increased in cases with endometrial pathologies. Addition of elastosonography modality to B-mode may improve the diagnostic accuracy during the follow-up of women using TAM for breast cancer.

Elastosonographic evaluation of patients with a sonographic finding of thickened endometrium.

OBJECTIVE: To evaluate if elastosonography of the endometrium can differ between normal endometrial tissue and abnormal pathology. STUDY DESIGN: One hundred and six women with a sonographic finding of thickened endometrium were enrolled in this study. All patients underwent B-mode scanning and elastosonography, performed by the same operator who was blinded to the study design. After sonographic evaluation, all patients underwent endometrial tissue sampling via dilatation and curettage. Histopathological results indicated that 22 patients had endometrial hyperplasia, 20 patients had endometrial polyps, and 64 patients had normal pathology results, with or without abnormal uterine bleeding. Groups were formed according to histopathological results, and ultrasonographic findings (strain ratio, endometrial thickness) were compared. RESULTS: Median age was 46 [interquartile range (IQR) 4] years, 37 (IQR 10) years and 36 (IQR 10) years for the endometrial hyperplasia, endometrial polyps and normal pathology groups, respectively. Median age of the endometrial hyperplasia group was significantly higher compared with the endometrial polyps and normal pathology groups (p<0.001). Median parity was 3 (IQR 2), 2 (IQR 1) and 3 (IQR 1) for the endometrial hyperplasia, endometrial polyps and normal pathology groups, respectively; differences between the groups were not significant (p=0.102). No differences were found between the groups in terms of endometrial thickness (p>0.05). When elastosonographic strain (B/A) ratios were compared between the groups, the endometrial hyperplasia and endometrial polyps groups had significantly lower B/A ratios (higher elasticity) than the normal pathology group (p<0.001). There was no significant difference in B/A ratios between the endometrial hyperplasia and endometrial polyps groups (p>0.05). CONCLUSION: The elasticity of endometrial tissue, measured non-invasively via elastosonography, was similar in women with endometrial polyps and endometrial hyperplasia, but differed significantly compared with women with normal pathology who had a sonographic finding of thickened endometrium and abnormal bleeding as the presenting complaint. According to these results, elastosonography cannot be used as a diagnostic tool to differentiate between endometrial hyperplasia and endometrial polyps. However, elastosonography can be used to differentiate between pathological endometrial changes and normal endometrium in patients presenting with a sonographic finding of thickened endometrium.

Investigation of cardiovascular disease risk in women with uterine leiomyomas.

OBJECTIVE: The aim of this study was to investigate the cardiovascular disease risk of patients with uterine leiomyoma using carotid intima-media thickness (CIMT), insulin resistance and lipid profile. METHODS: A total of 84 reproductive-aged women (20-45 years) were divided into two groups as the study group (n = 42) of women with leiomyoma and the control group (n = 42) of healthy women without leiomyoma. The risk factors for cardiovascular disease such as age, body mass index (BMI), low-density lipoprotein (LDL), triglycerides (Tg), high-density lipoprotein (HDL), total cholesterol and lipoprotein a levels, systemic disorders, cigarette smoking and CIMT were all recorded and compared between groups. RESULTS: The mean age, gravida, parity, BMI, total cholesterol level and CIMT were significantly different between the groups (p < 0.05). CIMT after adjusted for the age and age, BMI was significantly lower in study groups (<0.001). Insulin resistance, serum LDL, Tg, HDL, lipoprotein a, and endometrial thickness were comparable between groups (p > 0.05). The number of leiomyoma was significantly correlated with Tg (r = 0. 322, p = 0.037) and LDL (r = 0. 431, p = 0.006). The size of leiomyoma was significantly correlated with HOMA-IR values (r = -0.370, p = 0.016). CONCLUSION: Uterine leiomyoma was associated with lipid profile, insulin resistance and CIMT in reproductive-aged women.

Experience with different techniques for the management of postpartum hemorrhage due to uterine atony: compression sutures, artery ligation and Bakri balloon.

OBJECTIVES: To report our experience with different management approaches to treat postpartum hemorrhage (PPH) due to uterine atony with reference to need for hysterectomy. METHODS: A retrospective study of data of all women who delivered in Dr. Sami Ulus Medical and Research Hospital between April 2010 and April 2013 was collected from the department's medical records, to identify patients who had undergone the compressive suture techniques, artery ligation, Bakri balloon application and hysterectomy operation because of PPH due to uterine atony. RESULTS: A total of 32 cases who had PPH due to uterine atony were identified. Bleeding was successfully treated without the need for hysterectomy in 25 patients. Compressive suture technique and artery ligation without Bakri balloon application were used in 22 patients with the success rate of 72.7%. Bakri balloon was applied to ten patients, and there were three cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch suture) and one patient needed hysterectomy. The overall success rate of intrauterine balloon tamponade alone was 70%. The success of Bakri balloons in combination with artery ligation and B-Lynch suture was promising. CONCLUSION: Our case series suggest that in the condition of PPH due to atony, both compression sutures and Bakri balloon tamponade are effective methods. In combination of uterine artery ligation and B-Lynch suture with Bakri balloon tamponade might be the best surgical approach due to its higher success according to our results. To obtain more information further studies with large case series are important.

Association between urinary angiotensinogen, hypertension and proteinuria in pregnant women with preeclampsia.

INTRODUCTION: Preeclampsia is a life-threatening disorder of pregnancy. The pathogenic mechanisms of preeclampsia remain uncertain. The aim of this study is to investigate the relation between urinary angiotensinogen (UAGT) levels, an indicator of local renin-angiotensin system (RAS) activity in the kidney, and blood pressure and urinary protein excretion in preeclampsia. MATERIALS AND METHODS: For this study, 90 women aged between 20-39 years were recruited. Spot urine samples were collected to measure urinary angiotensinogen/creatinine ratio (UAGT/UCre). Log(UAGT/UCre) was compared in pregnancies with and without preeclampsia and non-pregnant controls. Factors affecting log(UAGT/UCre) in pregnancies were also investigated. RESULTS: In all pregnancies log(UAGT/UCre) levels were significantly higher than in non-pregnant controls (0.58±0.19 vs. 0.33±0.14, respectively, p=0.002). However, log(UAGT/UCre) levels in pregnancies with preeclampsia were slightly lower than in normal pregnancies (0.52±0.18 vs. 0.64±0.19, respectively, p=0.012). Log(UAGT/UCre) levels were correlated positively with blood pressure and proteinuria in pregnancies with preeclampsia. However, log(UAGT/UCre) levels were not correlated with age, height, body weight, gestational age, body mass index, and serum creatinine. CONCLUSION: This study showed that elevated local RAS activity in kidney was correlated with high blood pressure and proteinuria in preeclampsia. Local RAS activation in the kidneys may be one of the contributing factors in the development of preeclampsia.

A predictor of small-for-gestational-age infant: oral glucose challenge test.

OBJECTIVE: This study was performed to investigate the role of first-hour 50-g oral glucose challenge test (GCT) parameters in predicting the risk of delivering a small-for-gestational-age infant and to determine the accuracy of estimated fetal weight. METHODS: We screened 2,643 pregnant women >20 years of age and excluded 552 patients according to exclusion criteria. Newborns were assigned to three groups as SGA(n:100), AGA(n:100), and LGA(n:100) according to birth weight. All mothers received 50-g GCT in their 24-28th weeks of gestation. We examined the relationship between birthweight and test results. RESULTS: First-hour serum glucose level after the test significantly predicted babies with small for gestational age. Optimal cutoff value was obtained at a level of 74.5 mg/dl with 67% sensitivity and 55% specificity. The estimated fetal weight of Hadlock 5 formula was strongly correlated with the birth weight (Pearson r = 0.89). CONCLUSION: Our study revealed that 50-g oral glucose challenge test may predict small-for-gestational-age cases with 67% sensitivity, and our data revealed that there is a significant correlation between estimated fetal weight of Hadlock 5 formula and the birth weight.

Utility of superior mesenteric artery Doppler and maternal pancreatic size for predicting gestational diabetes mellitus.

AIM: The aim of this study was to assess the relationship between the maternal superior mesenteric artery Doppler, pancreatic size and gestational diabetes mellitus (GDM). METHODS: Two hundred and fifty-eight consecutive, pregnant women between 20 and 22 weeks of gestation underwent routine fetal anomaly screening. All subjects underwent maternal superior mesenteric artery Doppler and pancreatic size measurement of head, corpus and tail during screening. Screening was done with 50 g glucose challenge test (GCT) at gestational age 24-28 weeks. The patients who were having an abnormal GCT were subjected to 100 g GCT. Subjects were divided into two groups such as pregnancies with gestational diabetes and normal pregnancies. Relationship between Doppler and pancreatic measurements with GDM was analyzed. RESULTS: Out of 258 screened pregnancies, 28 (10.9 %) were diagnosed as GDM. There were significant differences between GDM positive and negative cases in terms of pancreatic body size (17.5 vs. 14.4 mm, p = 0.05), superior mesenteric artery Doppler systolic/diastolic ratio (S/D) (4.2 vs. 3.4) and resistance index (RI) (0.72 vs. 0.68) values. Superior mesenteric artery Doppler S/D (AUC = 0.761, p < 0.001) and RI (AUC = 0.762, p < 0.001) indices were significant predictors for GDM. CONCLUSION: Superior mesenteric artery Doppler and pancreatic size evaluation may be utilized to detect abnormal glucose metabolism during pregnancy care.

Chemical ablation of endometrium with trichloroacetic acid.

OBJECTIVES: The aim of this study was to assess the efficacy of topically applied trichloroacetic acid (TCA) for endometrial ablation in patients with dysfunctional uterine bleeding (DUB). This trial has also compared the advantages of prethinning the endometrium with danazol and goserelin acetate before ablation with TCA. METHODS: This prospective trial was conducted on 90 volunteer cases. Patients were allocated into three treatment groups comprised of 30 patients. In group I cases underwent dilatation and curettage before endometrial ablation. In group II cases were administered danazol before ablation. Cases in group III received goserelin acetate on the same day and 28 days after ablation. Endometrium was evaluated by biopsy, transvaginal ultrasonography and hysteroscopy. Endometrial ablation was performed with 95% TCA. All of the patients were evaluated 3 and 6 months after TCA application. RESULTS: After 6 months of treatment, the success rate was recorded as 83% in the first group, 92.3% in the second group and 96.6% in the third group. The mean length of uterine cavity was reduced in all groups, being only significant in Goserelin group (P<0.5). Endometrial thickness was decreased significantly in all treatment groups (P<0.001). CONCLUSIONS: This study concluded that endometrial ablation by TCA may readily be performed as an alternative treatment method in the management of DUB. Moreover, suppression of endometrium with danazol or especially with goserelin acetate before ablation, resulted in significant success rate.

Changes in leukocyte, granulocyte and lymphocyte counts following antenatal betamethasone administration to pregnant women.

OBJECTIVE: Preterm labor and premature rupture of membranes are associated with a mild leukocytosis. However, we have observed a higher maternal leukocyte count after antenatal betamethasone therapy. We planned this study to evaluate the effects of antenatal betamethasone treatment on maternal leukocyte, granulocyte and lymphocyte count. METHODS: Forty-six pregnant women with the diagnosis of preterm labor between 28 and 33 weeks of gestation age received 12 mg betamethasone at a 12-h interval. The control group consisted of 50 pregnant women between 28 and 33 weeks of gestational age with no medical or obstetrics problems. After a baseline venous sampling, serial leukocyte, granulocyte and lymphocyte counts were obtained every 6 h until it returned to baseline value. RESULTS: There were no statistically significant differences in the control group with respect to the total leukocyte, lymphocyte, and neutrophil count. Total leukocyte and granulocyte counts were increased by 29.8% and 17.8% within 24 and 12 h after betamethasone injection, respectively (P < 0.01). A significant reduction in lymphocyte count was observed within 12 h (45.4%) after betamethasone injection (P < 0.01). All changes in leukocyte, granulocyte and lymphocyte counts returned to baseline values within 3 days. CONCLUSION: Antenatal betamethasone therapy leads to an increase in maternal leukocyte count and a decrease in lymphocyte count. This effect is transient and any leukocytosis persisting for more than 3 days is not due to betamethasone administration.

Comparison of labor induction with misoprostol vs. oxytocin/prostaglandin E2 in term pregnancy.

OBJECTIVE: To compare the efficacy and safety of intravaginal and oral misoprostol vs. oxytocin/prostaglandin E2 (PGE2) gel for third trimester labor induction. METHODS: Two hundred twenty-four pregnant women were randomized to induction of labor either with misoprostol or oxytocin and PGE2 gel. Patients in the misoprostol group (n = 112) received 100 micrograms intravaginal misoprostol followed by 100 micrograms p.o. every 2 h. The oxytocin/PGE2 group consisted of 112 patients who underwent PGE2 cervical instillation 6 h before continuous oxytocin infusion. The perinatal, intrapartum and neonatal characteristics of both groups were determined. RESULTS: Induction to active phase of labor was successfully achieved in 96 women (85.7%) in the misoprostol group vs. 86 women (76.8%) in the oxytocin/PGE2 group, but the drug initiation-delivery interval was significantly shorter in the misoprostol group (9.2 +/- 2.4 h) than in the oxytocin/PGE2 group (15.2 +/- 3.2 h, P < 0.001). The incidence of adverse intrapartum outcomes was similar for both methods. Intravaginal misoprostol 100 micrograms followed by a single oral dose of 100 micrograms misoprostol safely produced labor and a vaginal delivery in 70% of patients. More than three tablets were required in only 10% of patients. There was a higher prevalence of cesarean section for failed induction in the oxytocin/PGE2 group than in the misoprostol group (13.4 vs. 6.3%, P < 0.001). The neonatal outcomes of both groups were also similar. CONCLUSION: Misoprostol is significantly more effective for labor induction than oxytocin/PGE2 gel. The maternal intrapartum and neonatal outcomes were the same for both induction regimens. From a clinical and perinatal perspective, misoprostol is an acceptable choice for labor induction.

Pelvic and periaortic pertioneal closure or non-closure at lymphadenectomy in ovarian cancer: effects on morbidity and adhesion formation.

The effects of pelvic and periaortic peritoneal closure or (non-closure) on morbidity and adhesion formation were prospectively compared in 102 patients with ovarian cancer who had undergone a pelvic and periaortic lymphadenectomy. Hysterectomy with bilateral salpingoophorectomy, bilateral pelvic and periaortic lymphadenectomy, omentectomy, appendectomy and lysis of pelvic adhesions for the standardization of initial adhesion scores was performed on all patients. The pelvic and periaortic peritoneum were re-approximated in group I (n = 50) patients, and left open in group II (n = 52) patients. The groups were similar for mean age, previous surgery, tumour histology and disease stage. Morbidity characteristics such as blood loss, transfusion rate, post-operative infectious and non-infectious complications, and total hospital stay were also similar. After six courses of PAC (cisplatin 50 mg/m(2), Adriamycin 50 mg/m(2), cyclophosphamide 500 Mg/M(2)) chemotherapy, all patients underwent a second-look laparotomy. Persistent cancer was detected in 49 of 102 (48.03%) patients. Adhesion scores were detected at the time of second-look laparotomy. Adhesion scores for group I (8.9 +/- 2.9) were significantly higher than the group II (peritoneum non-closure) (5.8 +/- 2.3) (P<0.01). Closing the pelvic and periaortic peritoneum did not effect morbidity, but leaving the pelvic and periaortic peritoneum open significantly decreased the adhesion formation.

Grasp reflex strength from right and left hands is associated with pH stressor from the umbilical arterial blood in human newborns: handedness and sex-related differences.

Grasp reflex and its asymmetry was studied in relation to pH of the umbilical blood in human newborns, to examine whether the degree of acidity in fetal blood (birth stress) is associated with cerebral laterality. Low pH values were considered as an index for birth stress. Grasp-reflex strength was found to be directly related to pH in total sample. There were sex-related differences. Namely, this correlation was true only for female newborns, not for males. Right minus left grasp-reflex strength linearly increased with pH, i.e., low pH values were associated with left-hand dominance, but only in males. The grasp-reflex asymmetry was not related to pH in females. It was concluded that blood pH may be associated with motor asymmetry and motor development in human newborns, but show sex-related differences; female brain seemed to be more sensitive to pH changes than male brain. The results partly supported the Bakan's hypothesis that birth stress may be associated with left-handedness.

Choriocarcinoma associated with ectopic pregnancy after tubal sterilisation.

A 33-year-old highly parous woman developed severe abdominal pain and signs of circulatory collapse 10 months after tubal sterilisation in the absence of symptoms of pregnancy. A ruptured ectopic pregnancy sited interstitially in the right tube and extending into the myometrium and parametrium was found at laparotomy. Histopathologic examination revealed an ectopic pregnancy consisting of choriocarcinoma--a rare but life-threatening combination in a sterilised woman.

Management of invasive cervical cancer in patients initially treated by simple hysterectomy.

This study includes 15 patients with invasive cervical cancer found at the time of standard hysterectomy for benign conditions. All patients underwent laparotomy and were subjected to peritoneal cytology, radical parametriectomy, bilateral pelvic and para-aortic lymphadenectomy. Residual disease was found in 10 of the 15 patients (66.7%). The 3-year survival of patients with and without residual disease were 80% and 100%, respectively. Following secondary radical surgery, five patients without evidence of residual disease were identified and spared the risks of radiation therapy. Furthermore, two patients with para-aortic lymph node metastases, who would otherwise have been overlooked, were thus treated completely. One patient died of complications of secondary surgical procedure.