The Value of Total antioxidant Status and Serum Tumor Necrosis Factor-α Levels at 24-28 Weeks of Gestation in the Prediction of Optimal Treatment Protocol in Gestational Diabetes Mellitus.

AIM: The aim of this study was to investigate the serum oxidative stress markers, antioxidant enzyme and tumor necrosis factor-α (TNF-α) levels at 24-28 weeks of gestation and to evaluate the predictive value of them on the subsequent treatment protocol in gestational diabetes mellitus (GDM). METHODS: A total of 58 GDM patients (30 treated with only conventional healthy dietary recommendation (CHDR), 28 treated with insulin) and 30 healthy pregnant women at 24-28 weeks of gestation, were enrolled in this prospective case-control study. The oxidative status, antioxidant enzyme and TNF-α levels were evaluated to determine if there is an association with the need of insulin therapy for glycemic control by using multivariable logistic regression analysis. RESULTS: TNF-α (OR=11.976, 95%CI: 2.441-58.754, P=0.002) and total antioxidant status (TAS) (OR=12.769, 95%CI: 2.464-66.182, P=0.002) were found to be predictive for GDM at 24-28 weeks of gestation. Besides, further evaluation considering the treatment modality showed that increased TNF-α (OR=18.615, 95%CI: 2.338-148.240, P=0.006) and lower TAS levels (OR=99.471, 95%CI: 2.865-3 453.061, P=0.011) were independent predictors of the need for insulin treatment in GDM patients. CONCLUSIONS: Increased TNF-α levels and low TAS are significantly associated with the increased risk of insulin requirement for achieving good glycemic control in GDM.

3Ds: decorin, discordance, and diamniotic dichorionic twins.

aullimary Investigation: The cause of discordance in dichorionic diamniotic (DD) twins is still unknown. The authors aimed to compare decorin (DCN) and oxidative/antioxidative state levels between the placentas of discordant and concordant twins. MATERIALS AND METHODS: Prospective study of 43 spontaneous DD twin pregnancies included and placentas samples taken from each twin and prepared for homogenization. Total oxidant/antioxidant status levels in placental tissue were determined by automated colorimetric method. Decorin levels were detected by using ELISA method; 23 of these were discordant and 20 of them were concordant. RESULTS: DCN levels in the placentas of the low birth-weight twins were significantly lower than the levels of the placentas of appropriate gestational age twins (p = 0.006). There were no statistically significant differences in total antioxidant status (TAS), total oxidant status (TOS), or arylesterase (ARES) levels in discordant (p = 0.631, p = 0.370, and p = 0.079, respectively) and in the placental DCN, TAS, TOS, or ARES levels of the concordant twins (p = 0.407, p = 0.035, p = 0.194, and p = 0.979, respectively). When the authors compared the twins of similar birth weight, the DCN, TAS, and TOS levels were significantly lower in the discordant twins (p < 0.001, p < 0.001, and p = 0.002, respectively). CONCLUSIONS: Decreased levels of DCN in discordant twin fetuses compared to the same birth weight-concordant twins shows that it contributes to disease pathogenesis.

Effect of intrahepatic cholestasis of pregnancy on maternal serum screening tests.

OBJECTIVE: In this study, we aimed to evaluate whether the changes in the first and second trimester maternal serum biochemical markers used for prenatal screening are associated with euploid pregnancies complicated by intrahepatic cholestasis of pregnancy (ICP). METHODS: A total of 94 pregnant women were included in this retrospective comparative study. Thirty-seven women whose pregnancy was complicated with ICP constituted the study group whereas 57 of them constituted the control group. All hospital records were examined in terms of combined first trimester screening test and second trimester triple test parameters. Perinatal outcomes were also recorded. RESULTS: No significant difference was observed between the two groups in term of age, BMI, and obstetric history (all p > 0.05). Mean serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and serum bile acid concentrations in the study group were significantly higher than in the controls (p < 0.001). There were no significant differences between the two groups in terms of first and second trimester serum biochemical markers. Newborn gender, route of birth, and NICU admission rates were also similar in the two groups. Mean birth weight of the control group was statistically significantly higher than the ICP group (p = 0.012). CONCLUSION: We report no significant differences between pregnancies complicated by ICP and healthy pregnancies in terms of first and second trimester maternal serum screening test results.

Anterior placenta previa is associated with increased umbilical cord blood hematocrit concenrations.

OBJECTIVE: We aimed to evaluate the umbilical cord blood (CB) hematocrit (Hct) levels in women with anterior located placenta previa (PP). METHODS: This is a prospective case-control study performed in a tertiary level maternity hospital. Thirty seven pregnant women diagnosed with anterior PP (study group) and 37 women without PP (control group) included into the study. Groups were matched with regard to age, gestational age, and fetal gender. All women underwent Cesarean section. Umbilical CB Hct levels of the newborns were measured. Demographics, operative features, and neonatal outcomes were recorded. RESULTS: Umbilical CB Hct levels were statistically significantly higher in the PP patients compared with controls (p: 52.6±5.0 vs. 47.5±5.0, p < 0.001). Preoperative maternal hemoglobin (Hgb) and Hct levels were similar in the two groups. However, postoperative Hb and Hct levels were significantly lower in the study group (p: 0.003, p < 0.001, respectively). Intraoperative complication rates were higher in this group. Neonatal Apgar scores were lower and neonatal intensive care unit admission was more common in the PP group when compared with controls. CONCLUSION: We think that anterior PP is associated with increased umbilical CB Hct levels. Neonatologists should consider this condition in the infants born to mothers with anterior PP.

Comparison of plasma fetuin A levels in patients with early-onset pre-eclampsia vs late-onset pre-eclampsia.

OBJECTIVE: Pre-eclampsia (PE) is among the most commonly researched topics in perinatology. Fetuin-A (FA), a multifunctional protein, has roles in the inhibition of ectopic calcification and the regulation of serum glucose levels. Reduced FA is an indicator of inflammation. This study was performed to investigate the potential role of inflammation in the pathophysiology of early- and late-onset PE by measuring FA levels. STUDY DESIGN: In total, 110 patients were included in this study. Early- and late-onset PE were defined as a diagnosis at <34 weeks or ≥34 weeks of gestation, respectively. Plasma FA levels were determined by immunoassay, which was performed in duplicate using a sandwich enzyme-based technique. Parametric data were appraised using an independent two-sample t-test, and non-parametric data were compared using the Mann-Whitney U-test. Multivariate logistic regression was performed to investigate the impact of certain parameters on PE. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of FA. RESULTS: There were 24 patients with early-onset PE and 19 gestational-age-matched controls. Plasma FA levels were significantly lower in the early-onset PE group compared with the controls (17.3±3.3ng/ml vs 21.4±3.5ng/ml, p<0.05). There were 36 patients with late-onset PE and 31 gestational age-matched controls. Plasma FA levels were significantly higher in the late-onset PE group compared with the controls [26.1ng/ml (range 13.4-52.0) vs 18.4ng/ml (range 14.9-24.9), p<0.05]. Besides the parameters used in the diagnosis of PE, the single most important variable related to PE was FA. The optimal cut-off level for FA in the prediction of early-onset PE was 19.6ng/ml [sensitivity 79%, specificity 83.3%, area under the curve (AUC) 0.796, 95% confidence interval (CI) 0.650-0.943, p=0.001]. FA did not show a statistically discriminative value in differentiating late-onset PE from control subjects (AUC 0.196, 95% CI 0.085-0.306). CONCLUSION: Early- and late-onset PE were associated with lower and higher levels of FA, respectively. A relationship was found between inflammation and early-onset PE but not late-onset PE.

Alterations in lipid peroxidation and T-cell function in women with hyperemesis gravidarum.

The objective of this study was to investigate serum adenosine deaminase (ADA) activity as a marker of T lymphocyte activation and parameters of oxidative stress and antioxidant defence in hyperemesis gravidarum (HG). Serum ADA activity, malondialdehyde (MDA), catalase (CAT) and glutathione peroxidase (GPx) levels were investigated in 40 pregnant women with the HG and 40 with healthy pregnancies, in a descriptive study. Although serum ADA and CAT were measured to be higher in HG group, the difference was not significant. Serum MDA and GPx levels were significantly elevated in women with HG when compared with those without HG. The significance of changes in lipid peroxidation and T-cell activation in the pathogenesis of HG and whether this is a cause or a compensatory reaction to HG requires further investigations with larger multicentre trials.

Retrospective evaluation of risk factors and perinatal outcome of umbilical cord prolapse during labor.

OBJECTIVE: Umbilical cord prolapse has a reported prevalence of 0.1-0.6%. In previous studies, risk factors for umbilical prolapse have been identified as multiparity, preterm delivery, non-vertex presentation, and obstetric manipulation for labor induction. In the present study, we aimed to investigate the risk factors for umbilical cord prolapse and to determine the factors that may relate to neonatal morbidity in these patients. PATIENTS AND METHODS: This study consisted of recorded cases of umbilical cord prolapse at Dr Zekai Tahir Burak Research and Training Hospital between January 2008 and May 2013. Clinical and demographic data were obtained by reviewing the patients' medical records. Student's t test was performed for parametric variables between groups, and a Chi-square test was performed for nonparametric variables between groups. A logistic regression was performed to investigate the effects of clinical parameters such as gestational age, diagnosis to delivery interval, and fetal presentation on neonatal morbidity. RESULTS: The patients with umbilical cord prolapse during labor had higher rates of preterm deliveries, low-birth-weight infants, and non-vertex presentations than the control group did. Preterm delivery, non-vertex presentation, presence of polyhydramnios, and spontaneous membrane rupture increased the risk of umbilical cord prolapse significantly. In the regression analysis, gestational age and diagnosis to delivery interval greater than 10 minutes predicted adverse neonatal outcomes independently. CONCLUSIONS: Umbilical cord prolapse is more common in cases of preterm delivery, non-vertex fetal presentation, and spontaneous rupture of membranes. A diagnosis to delivery interval greater than ten minutes is independently associated with an adverse neonatal outcome.

Levels of neopterin and C-reactive protein in pregnant women with fetal growth restriction.

The aim of this study was to evaluate whether pregnant women with fetal growth restriction (FGR) have higher plasma neopterin and C-reactive protein (CRP) concentrations compared with those with uncomplicated pregnancy. A total of 34 pregnant women with FGR and 62 patients with uncomplicated pregnancy were included. Neopterin and CRP levels were measured at the time of diagnosis. The primary outcome of this study was to compare the neopterin and CRP levels in pregnant women with FGR and those with uncomplicated pregnancies. The secondary outcome of our study was to evaluate the correlation between fetal birth weight and maternal neopterin levels. The serum neopterin levels were significantly elevated in pregnant women with FGR (22.71 ± 7.70 vs 19.15 ± 8.32). However, CRP was not elevated in pregnant women with FGR (7.47 ± 7.59 vs 5.29 ± 3.58). These findings support the hypothesis that pregnancy with FGR is associated with a marked increase in macrophage activation and the natural immune system.

Successful use of BT-Cath(®) balloon tamponade in the management of postpartum haemorrhage due to placenta previa.

OBJECTIVE: To investigate efficacy of the BT-Cath(®) in cases of uncontrollable haemorrhage due to placenta previa. STUDY DESIGN: Retrospective study of women treated with the BT-Cath in the event of postpartum haemorrhage (PPH) due to placenta previa, despite optimal management with medical treatment. RESULTS: Between 2011 and 2013, 237 women had placenta previa (0.45%) at the study hospital. This study evaluated 53 women who underwent uterine tamponade with a BT-Cath. Haemostasis was achieved in 45 women (85%), and hysterectomy was required in six women (11%). Two women required repeat laparotomy. The mean duration of balloon tamponade was 9.8h (standard deviation 6.4h). When the relationship between balloon volume and treatment success was evaluated, the area under the receiver operating characteristic curve was 0.803 (95% confidence interval 0.633-0.973; p=0.007) and the optimal cut-off point was 220ml, with sensitivity of 88% and specificity of 71%. CONCLUSION: The intra-uterine BT-Cath is simple to use, even among clinicians with little experience, and is an effective treatment choice in patients with PPH due to placenta previa when medical treatment is unsuccessful. Minimal inflation of the balloon, a shorter period of intra-uterine balloon tamponade and early deflation of the balloon are recommended.

Dehydroepiandrosterone supplementation improves predictive markers for diminished ovarian reserve: serum AMH, inhibin B and antral follicle count.

OBJECTIVE: To evaluate the effect of dehydroepiandrosterone (DHEA) supplementation on ovarian reserve by measuring markers such as antral follicle count, serum anti-Müllerian hormone (AMH) and inhibin B in patients with diminished ovarian reserve. STUDY DESIGN: This prospective study was undertaken at Dr. Zekai Tahir Burak Women's Health Research and Education Hospital, Ankara, Turkey. Forty-one patients with diminished ovarian reserve were included in the study and received supplementation with DHEA 25mg, t.i.d., for at least 6 weeks. Serum AMH, inhibin B, follicle-stimulating hormone (FSH) and oestradiol, and antral follicle count were determined before and after DHEA supplementation. Baseline ovarian reserve parameters such as antral follicle count, FSH, oestradiol, AMH, inhibin B, clinical and laboratory IVF outcomes, and pregnancy rates were studied. RESULTS: There were significant differences in day 3 FSH, oestradiol, antral follicle count, AMH and inhibin B levels before and after DHEA supplementation in all patients (p=0.001, 0.001, 0.002, 0.001 and 0.001, respectively). The study population was divided into two age groups (<35 and ≥35 years) to determine whether there was a difference in the effect of DHEA supplementation between younger and older patients with diminished ovarian reserve. Significant differences were found in all of the parameters in both study groups (p<0.05). CONCLUSIONS: DHEA supplementation is an effective option for patients with diminished ovarian reserve. Prior to assisted reproductive technology, patients with diminished ovarian reserve should be offered DHEA supplementation as an alternative to oocyte donation.

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.

Efficacy of pulsed estrogen therapy in relatively younger patients with surgically induced menopause.

BACKGROUND: Pulsed estrogen therapy is a new approach in estrogen replacement therapy. We carried out a prospective study to evaluate the efficacy of pulsed estrogen therapy in relatively younger patients with surgically induced menopause. METHODS: Patients (n=138) <45 years old and suffering from severe vasomotor symptoms secondary to surgically induced menopause were included in the study. After the initiation of pulsed estrogen therapy (300 microg/day), the patients were re-evaluated every 4 weeks. The dose was increased at each follow-up, if necessary (to a maximum of 600 microg/day). The patients who preferred another method after the first 12 weeks were prescribed oral conjugated estrogen (0.625 mg/day) and at the end of the second 12 weeks their satisfaction levels were assessed. RESULTS: At the end of the first 12 weeks, 26 patients were completely satisfied (18.8%) and 47 were moderately satisfied (34.1%), whereas 65 concluded that the pulsed estrogen therapy they received was ineffective (47.1%). At the end of the second 12 weeks, all the patients were completely satisfied. CONCLUSION: Pulsed estrogen therapy for 12 weeks reduced the frequency of hot flushes in relatively younger patients with surgically induced menopause; however, 81.2% of patients were not completely satisfied at the end of this period.

Recurrent empty follicle syndrome.

We report a case of a recurrent empty follicle syndrome. The patient was admitted to our intracytoplasmic injection program because of her partner's azoospermia. Ovarian stimulation was accomplished using gonadotrophin therapy after treatment with oral contraceptive pills followed by gonadotrophin-releasing hormone agonist. Thirty-six hours after the administration of HCG (human chorionic gonadotrophins), transvaginal oocyte retrieval yielded no oocytes despite the aspiration and flushing of all available follicles. Two years later, a second treatment cycle was started using the same pituitary desensitisation and ovarian stimulation regimens. HCG from a different batch with respect to that used in the first treatment cycle was administered. Aspiration and repeated flushing of all follicles of one ovary failed to yield any identifiable oocyte. The beta-HCG and progesterone serum concentrations on the day of retrieval were 181 mIU/mL and 3.79 ng/mL, respectively. New oocyte retrieval was planned 6 h after the first attempt for aspiration of follicles. Again, no ova were obtained at this second trial despite the aspiration of the all follicles. As to our knowledge this is the first report of recurrent EFS (empty follicle syndrome) and managed without repeating the HCG injection on the day of unsuccessful oocyte retrieval.

Risk factors and infant outcomes associated with umbilical cord prolapse.

OBJECTIVES: Our goal was to identify risk factors associated with umbilical cord prolapse and to review the perinatal outcome of cases of cord prolapse. METHODS: During the study years 77 cases were identified retrospectively. Associations between cord prolapse and potential risk factors were evaluated by means of the odds ratio. RESULTS: Of the 77 fetuses with umbilical cord prolapse 9.1% had a fetal weight of < 2500 gas compared with 9.4% for fetuses in control group (P > 0.05). The umbilical cord prolapse occurred in association with vertex presentation 66 times (85.7%), breech presentation nine times (11.7%) and transverse presentation two times (2.6%). The occurrence of breech presentation among the control cases was 2.6%, and that of transverse lie was 1.7% (P < 0.01). Case mothers were 1.6 times more likely to be multiparas compared with the control group (P < 0.01). The perinatal mortality rate was 39/1000. CONCLUSIONS: Our study showed that abnormal fetal presentation and multiparity are associated with an increased risk of umbilical cord prolapse. The association of risk of cord prolapse with low birth weight was statistically insignificant (P > 0.05). We suggest that the cesarean delivery decreased the risk of perinatal mortality among cases of cord prolapse.

Inevitable hysterectomy despite conservative surgical management in advanced cervical pregnancy: a case report.

A 35-year-old woman was diagnosed to have cervical pregnancy of 10.2 weeks duration. Methotrexate therapy was not chosen due to the presence of active tuberculosis. Since the patient had gradually increasing vaginal hemorrhage, she was taken to the operating room. A dilatation and curettage could not control the hemorrhage. A laparotomy was performed and the uterine arteries were ligated. A cervical hysterotomy was also performed to evacuate the products of conception. There was active bleeding in the cervix although no products of conception were observed. Two purse string sutures were placed, but the persistence of profuse bleeding despite these measures necessitated total hysterectomy.

Reasons why women have induced abortions in a developing country.

OBJECTIVE: The immediate explanation that women often give for seeking induced abortion is that the pregnancy was unplanned or unwanted. However, the myriad social, economic and health circumstances that underlie such explanations have not yet been fully explored. We wanted to evaluate these factors that lead one to have an abortion. STUDY DESIGN: This prospective study was performed on 588 women applied to our family planning unit to obtain an abortion. Analysis is based on the records of the women's age, educational level, their contraceptive usage and the reasons that they give for having an abortion. We also examined how these reasons were related to women's age, educational attainment and contraceptive choices. RESULTS: The desire to postpone a birth or to stop childbearing is a very common reason given by the women seeking abortion. It is seen that despite the women's desire to postpone or stop childbearing, the majority of them were not using an effective contraceptive method. Women's age is closely related to their reasons for seeking an abortion. On the other hand, we have found no clear association between women's educational level and their main reasons for seeking an abortion. CONCLUSION: Reasons women give for why they seek abortion are often far more complex than simply not intending to become pregnant. While improved contraceptive use can help reduce the unintended pregnancy and abortion, some abortions will remain difficult to prevent, because of limits to women's ability to determine and control all circumstances of their lives.