Prenatal ultrasonographic findings of adhesion-membrane complex and its relation with obstetric history.

Background: Intrauterine adhesions are usually detected incidentally during routine obstetric ultrasound and remain one of the reasons for concern for both clinicians and patients.Objective: Our objective was to document ultrasonographic findings of intrauterine adhesions detected in obstetric ultrasound and to investigate their correlation with obstetric history.Study Design: Detailed scans were performed in 685 singleton pregnancies at 16-24 weeks' gestation. Intrauterine adhesion was referred to as "adhesion-membrane complex'' (AMC). Patients were divided into three groups: Group I consisted of patients with ≥1 therapeutic D&C associated with pregnancy but with neither vaginal delivery nor Cesarean section (CS). Group II consisted of patients with ≥1 CS but with neither vaginal delivery nor therapeutic D&C associated with pregnancy. Group III consisted of patients who were in their first pregnancy. Ultrasonographic properties of AMC and relationship between AMCs and obstetric history were investigated.Results: The incidence of AMC in Group I (n = 108), Group II (n = 189), and Group III (n = 388) was 11.1% (n = 12), 1.05% (n = 2) and 1.03% (n = 4), respectively. Positive history of D&C is associated with significantly increased risk of AMC (risk ratio:10.778; 95% confidence interval: 3.55-32.75). Also, previous history of CS is not associated with significantly increased risk of AMC (risk ratio: 1.026; 95% confidence interval: 0.19-5.55). The AMCs were located in the upper half in 7 (38,9%) and in the lower half of the uterus in 11 (61.1%) patients. The midpoint thickness of the AMC was between 0.75 and 5.10 mm (mean: 2.65 mm; SD ± 1.2). The width of the AMC was between 2 and 52 mm (mean: 20.98; SD ± 15.3), the heights of the AMCs were 5-60 mm (mean: 33.27 mm; SD ±17.0). In ten of the AMC positive patients (55.6%) a thick and bulbous free end and in eleven of them (61.1%) a "Y image" was detected. The mean gestational age at birth was 37.4 (SD ± 3.3) weeks in 18 patients with AMC. There were no intrauterine fetal or perinatal deaths. None of the neonates had congenital abnormalities.Conclusions: Intrauterine adhesions detected in obstetric ultrasonography were redefined and renamed in a more comprehensible manner. Our results pointed out that while the positive history of D&C is associated with significantly increased risk of AMC, previous history of CS is not associated with significantly increased risk of AMC.

Symptoms and Health Quality After Laparoscopic and Robotic Myomectomy.

BACKGROUND AND OBJECTIVES: To compare the symptom severity and health quality outcomes of women who underwent laparoscopic and robotic myomectomy. METHODS: This was a prospective nonrandomized cohort study. The Uterine Fibroid Symptom and Health Related Quality of Life Questionnaire was administered to 33 laparoscopic myomectomy and 31 robotic myomectomy patients before and year after surgery. Symptom severity and health quality scores were compared between the preoperative and postoperative periods for laparoscopic and robotic myomectomy procedures. RESULTS: The mean age, operation time, estimated blood loss, body mass index, largest fibroid diameter, length of hospital stay, and number of fibroids removed were comparable for both groups (P > .05). Symptom severity scores decreased significantly for both laparoscopic and robotic myomectomy patients at year after surgery (P < .05), and health-related quality of life scores increased significantly in both groups at 1 year after surgery (P < .05). Improvement in symptom severity and health quality was higher in the laparoscopy group; however, this was not statistically different from the robotic myomectomy group (P > .05). CONCLUSION: Laparoscopic and robotic myomectomy provide significant reductions in fibroid-associated symptom severity and significant improvement in quality of life at 1 year after surgery. The rate of improvement was comparable for both procedures.

Sonographic findings and perinatal outcome of multiple pregnancies associating a complete hydatiform mole and a live fetus: a case series.

BACKGROUND: The aim of this case series was to present the ultrasonographic findings, clinical features, management, and outcome of multiple pregnancies with complete hydatidiform mole and coexisting fetus (CHMCF). METHODS: Sonographic features and obstetrical and perinatal outcomes of seven cases with CHMCF were analyzed retrospectively. RESULTS: A total of seven cases was included in the analysis. Six cases were twins and one case was quadruplet. The mean ± SD maternal age was 25.3 ± 1.9 years (median: 25; range: 23-29). The mean gestational age at diagnosis was 16.1 ± 4.6 weeks (median: 17; range: 11-23). Two pregnancies were achieved by ovulation induction. Two couples opted for pregnancy termination. Four pregnancies resulted in fetal loss between the 11th and 23th week of gestation. One pregnancy ended with the preterm delivery of a live-born neonate at 34 weeks due to pre-eclampsia. One patient developed persistent trophoblastic disease, which was treated by hysterectomy. The mean ± SD time for ß-human chorionic gonadotropin clearance was 3.7 ± 0.5 weeks (median: 4; range: 3-4) in the six patients without persistent trophoblastic disease. CONCLUSIONS: Spontaneous fetal loss is the most likely outcome for CHMCF. However, on the basis of our experience, we recommend carefully monitored continuation of pregnancy as long as maternal complications are not present or are controllable.

Oral tadalafil reduces intra-abdominal adhesion reformation in rats.

BACKGROUND: Currently, there is no ideal agent to prevent adhesion formation. We have shown that sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor, reduces post-operative adhesion formation by vasodilatation and increases fibrinolytic activity. Here, we evaluated whether tadalafil, a long-acting PDE-5 inhibitor, decreases post-operative adhesion reformation in rats. MATERIALS AND METHODS: Standardized lesions were created in Wistar albino rats by cauterization of uterine horns and abrasion of adjacent peritonium. The extent and severity of adhesions were scored on the 14th post-operative day and adhesiolysis was performed at the second laparotomy. Animals were then assigned randomly into two groups. The study group (n = 11) received 10 mg/kg oral tadalafil by gavage 60 min before the second laparotomy and daily for 14 days afterwards. Controls (n = 11) received the same volume of tap water for 14 days by gavage. Animals were killed 15 days after adhesiolysis and adhesions were scored blind during the third laparotomy. RESULTS Basal adhesion scores at the time of the second laparotomy were comparable in the study and control groups. Scores for the extent of adhesion reformation in the study and control groups did not differ [median 1 (range 0-3) versus median 2 (range 1-3); P: 0.81] but tadalafil reduced the respective severity scores [median 0.5 (range 0-1) versus median 1 (range 0.5-1); P: 0.02] and total scores [median 2 (range 0-4) versus median 2.5 (range 1.5-4); P: 0.042]. CONCLUSIONS: Oral administration of tadalafil during the perioperative period reduces intra-abdominal adhesion reformation in rats.

Idiopathic hirsutism: local and peripheral expression of aromatase (CYP19A) and 5α-reductase genes (SRD5A1 and SRD5A2).

OBJECTIVE: To evaluate idiopathic hirsutism etiology via molecular studies testing peripheral and local aromatase and 5α-reductase expression. DESIGN: Assessment of the expression of messenger RNA (mRNA) for type 1 and 2,5α-reductase isoenzyme gene (SDR5A1, SDR5A2) and aromatase (CYP19A) in dermal papillae cells and peripheral blood mononuclear cells. SETTING: University hospital. PATIENT(S): 28 untreated idiopathic hirsute patients and 20 healthy women (controls). INTERVENTION(S): Human skin biopsies and peripheral venous blood. MAIN OUTCOME MEASURE(S): SDR5A1, SDR5A2, CYP19A gene expression in skin biopsies and peripheral blood. RESULT(S): A statistically significant reduction of SRD5A1, SRD5A2, and CYP19A gene expression was found in the dermal papillae cells and peripheral blood mononuclear cell between the study and control group. CONCLUSION(S): Further study, including protein expression and enzyme activity assays, are warranted to characterize the paradoxically low gene expression levels of local 5α-reductase and aromatase in women with idiopathic hirsutism.

First trimester diagnosis of sacrococcygeal teratoma using two- and three-dimensional ultrasound.

Sacrococcygeal teratomas are very rarely diagnosed in the first trimester. Here we report a case of a presacral mass suggestive of a sacrococcygeal teratoma that was detected during the first trimester nuchal translucency thickness measurement at 12+1 week of gestation. Although the diagnosis was possible with conventional two-dimensional sonography, three-dimensional sonography facilitated prenatal counseling by providing more recognizable images to the parents. Postmortem examination of the fetus confirmed the presence of a type 2 benign immature teratoma.

Prenatal diagnosis of fetal hypothyroidism after maternal radioactive iodine exposure during pregnancy.

A 33-year-old woman with a history of surgically treated papillary thyroid carcinoma was inadvertently given radioactive iodine when she was 16 weeks pregnant. Sonographic examination revealed fetal thyroid hypoplasia, and cordocentesis confirmed fetal hypothyroidism at 22 weeks. The pregnancy was terminated at 24 weeks. We report the first case of fetal thyroid hypoplasia diagnosed by ultrasound and cordocentesis.

Prevention of paclitaxel and cisplatin induced ovarian damage in rats by a gonadotropin-releasing hormone agonist.

OBJECTIVE: To evaluate the protective effect of GnRH agonist for the prevention of ovarian reserve during treatment with paclitaxel and cisplatin. DESIGN: Experimental study. SETTINGS: University-based research laboratory. ANIMAL(S): Seventy female Wistar-Albino rats. INTERVENTION(S): Each group consisted of 10 rats. Group 1 served as controls. Groups without GnRH agonist (groups 2, 3, and 4) were administered paclitaxel and cisplatin, respectively; the remaining groups (groups 5, 6, and 7) were given the same regimens with GnRH agonist. The GnRH agonist (leuprolide acetate; 2.5 microg/d subcutaneously for 5 weeks) was started four weeks before chemotherapy to achieve anovulation. Paclitaxel (7.5 mg/kg) and cisplatin (5 mg/kg) were administered intraperitoneally on the 28th day as a single dose. MAIN OUTCOME MEASURE(S): One week after the chemotherapy, the animals were euthanized and primordial, primary, secondary, and tertiary follicle counts were evaluated. RESULT(S): Primordial, primary, and tertiary follicle counts in group 5 (paclitaxel plus GnRH agonist) and tertiary follicles in groups 2 and 3 had not decreased, but there was a significant decrease in other treatment groups compared with controls (P < 0.05). Binary comparison between all groups demonstrated that the primordial follicle count in group 5 was comparable to those of the controls. CONCLUSION(S): Paclitaxel plus GnRH agonist treatment may be an appropriate option for patients deserving further fertility in the preservation of primordial follicles.

Intrauterine device use does not increase the incidence of anti-hepatitis C seropositivity among monogamous women in Turkey.

BACKGROUND: The relationship between intrauterine device (IUD) use and anti-hepatitis C virus (HCV) status has not been investigated yet. The aims of this study were to compare anti-HCV seropositivity between IUD users and nonusers and to determine whether IUD use is an independent risk factor for anti-HCV seropositivity. STUDY DESIGN: This cross-sectional study included 302 married women who used either an IUD (n=164) or did not use any form of modern contraception (n=138). Statistical analysis was carried out using multiple logistic regression models. RESULTS: Most women were housewives and all indicated their husbands as the one and only lifetime sexual partner. None of the women have ever used intravenous drugs. There were no statistically significant differences between groups in any of the major risk factors for HCV exposure such as invasive dental procedures, parenteral injections, surgery and blood or blood product transfusions. Twenty-seven (8.9%) of the participants were anti-HCV-positive. Of these, 14 were IUD users and 13 were nonusers and there were no statistically significant differences between the two groups (p=.472). The most important risk factors for anti-HCV seropositivity were the number of deliveries (OR=1.41; 95% CI 1.07-1.86) and invasive dental procedures (OR=2.39; 95% CI 1.07-5.39). CONCLUSIONS: IUD use is not associated with an increased incidence of anti-HCV seropositivity among monogamous women. The IUD may be an appropriate contraceptive option for women in stable monogamous partnership with HCV carriers and condom use should not be specifically recommended in this situation.

Prenatal sonographic findings in a fetus with splenogonadal fusion limb defect syndrome.

Splenogonadal fusion limb defect syndrome (SGFLD) is a very rare abnormality. We report on a case with prenatal sonographic findings of a fetus with postnatally diagnosed SGFLD syndrome. This is also the second case of prenatal ultrasonographic diagnosis of gastrointestinal malrotation associated with SGFLD. A 26-year-old primigravid woman was referred to our clinic because of nonvisualization of both fetal femoral bones at 20 weeks of gestation. A detailed sonographic examination showed complete bilateral absence of lower limbs, micrognathia, single umbilical artery and a right-sided stomach. Autopsy confirmed prenatal sonographic findings and additionally showed that the spleen was abnormally connected to the left gonad by a fibrous band. In conclusion, although all limbs and both sides were equally affected in most of the reported cases, SGFLD syndrome should be considered in cases with terminal limb defects of lower limbs.

Removal of ascites up to 7.5 liters on one occasion and 45 liters in total may be safe in patients with severe ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) is a serious and potentially lethal complication of ovulation induction. We report herein a case with OHSS treated by serial vaginal paracentesis. A 31-year-old patient was hospitalized due to severe OHSS after in vitro fertilization (IVF)-embryo transfer. Transvaginal drainage was performed with a standard 17-gauge IVF needle connected to a vacuum pump through a drainage set in nine courses. We removed 45 liters of ascitic fluid in total and 7.5 liters of ascitic fluid in one course, leading to improvement of the patient's condition and laboratory parameters. In conclusion, removal of ascites up to 7.5 liters on one occasion and 45 liters in total by serial vaginal paracentesis may be performed in patients with severe OHSS.

Selective ovarian vein sampling can be crucial to localize a Leydig cell tumor: an unusual case in a postmenopausal woman.

Leydig cell tumors of the ovary are very rare, frequently associated with symptoms of virilization in postmenopausal patients. It is sometimes difficult to localize the tumor precisely even with modern imaging techniques. A 62-year-old patient presented with recent onset of rapidly progressive virilization including increased hirsutism, progressive balding, deepening voice and enlargement of the clitoris. Initial laboratory examination revealed a total serum testosterone level of 1330 ng/dL. Serum dehydroepiandrosterone sulfate, androstenedione and 17 hydroxyprogesterone levels were all within normal limits. Extensive pre-operative evaluations included transvaginal ultrasound, abdominal computed tomography and magnetic resonance imaging failed to localize the tumor. Therefore, selective ovarian venous hormonal sampling (SOVHS) was performed and they revealed that the total serum testosterone level was significantly higher in the left than in the right ovarian vein (7000 ng/dL vs. 225 ng/dL). A total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Microscopic examination of the left ovary revealed a Leydig cell tumor. In conclusion, when the precise location of the tumor is not determined pre-operatively, SOVHS may be valuable to make accurate diagnosis.

Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol.

OBJECTIVE: To compare the effectiveness of oral and vaginal misoprostol for preoperative cervical ripening in premenopausal women before hysteroscopic surgery. DESIGN: Placebo-controlled, double blind, randomized trial. SETTING: University hospital. PATIENT(S): Eighty-six premenopausal women eligible for operative hysteroscopy were recruited. Nine women were excluded from the study. INTERVENTION(S): Patients were randomly assigned to receive 400 microg of misoprostol orally (n = 39) or vaginally (n = 38), 10-12 hours before operative hysteroscopy. MAIN OUTCOME MEASURE(S): Extent of initial cervical width, percentage of patients requiring cervical dilatation, duration of cervical dilatation and surgical procedure, complications during procedure, and associated side effects. RESULT(S): Mean cervical widths in the vaginal and oral misoprostol groups after treatment were 7.3 +/- 1.6 mm and 6.0 +/- 1.5 mm, respectively, which was a statistically significant difference. Time required for cervical dilatation (98.6 +/- 88.7 s vs. 49.1 +/- 34.9 s) and duration of surgery (14.5 +/- 6 vs. 7.7 +/- 4.0 min) was statistically significantly shorter in the vaginal misoprostol group. The percentage of women with an initial cervical width of 9 mm was statistically significantly higher in the vaginal misoprostol group (36.8% vs. 5.1%). Uterine perforation occurred in two patients in the oral misoprostol group and in none in the vaginal misoprostol group. Side effects were comparable between the two treatment groups. CONCLUSION(S): Vaginal administration of misoprostol is more effective than the oral route for preoperative cervical ripening in premenopausal women.

Isolated torsion of the fallopian tube during pregnancy: a case report.

BACKGROUND: Isolated fallopian tube torsion during pregnancy is a rare condition, and only 16 cases have been reported. In all but 1 case the right tube was affected. We report the second case of isolated left fallopian tube torsion during pregnancy. CASE: A 23-year-old primigravida presented at 22 weeks of gestation with left lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the left uterine border. Laparotomy revealed torsion of the left hydrosalpinx together with a paraovarian cyst. The patient delivered a healthy infant at term after an otherwise-uneventful pregnancy. CONCLUSION: As the gravid uterus increases the risk for fallopian tube torsion, this condition should be included in the differential diagnosis of lower abdominal pain during pregnancy.

Comparison of two oral contraceptives containing either drospirenone or cyproterone acetate in the treatment of hirsutism.

Combined oral contraceptives (COCs) are considered the first-line treatment for women with hirsutism. They diminish androgen release from the ovary and decrease plasma free testosterone levels by increasing sex hormone-binding globulin (SHBG) concentrations. COCs containing cyproterone acetate (CPA) and drospirenone (DRSP) have been proved effective for the treatment of acne and facial hirsutism. This study prospectively compared the clinical and biochemical efficacy of 3 mg DRSP/30 microg ethinyl estradiol (EE) and 2 mg CPA/35 microg EE combinations in a total of 91 patients with hirsutism. Individuals randomly received a cyclic combination of either DRSP/EE (n=48) or CPA/EE (n=43) for 12 months. Basal serum total testosterone, free testosterone, androstenedione, dehydroepiandrosterone sulfate and SHBG levels, as well as Ferriman-Gallwey scores, were determined before and after treatment. Both COCs achieved a similar effect on clinical hirsutism scores, in addition to serum androgen and SHBG levels, after completion of therapy. The percentage reductions in total hirsutism score (median % (min-max)) during therapy were 0.70 (0-0.58) vs. 0.57 (0.10-1.00) at 6 months (p = 0.028) and 0.80 (0-0.42) vs. 0.81 (0-0.75) at 12 months (p = 0.6) in the DRSP/EE and CPA/EE groups, respectively. In conclusion, the DRSP/EE combination is at least as effective as the CPA/EE combination in improving hirsutism scores.

Sacrococcygeal teratoma in a fetus with prenatally diagnosed partial trisomy 10q (10q24.3-->qter) and partial monosomy 17p (p13.3-->pter).

OBJECTIVE: Clinical features of the distal 10q trisomy syndrome consist of mental retardation, facial dysmorphism and renal and cardiac anomalies. The presence of a sacrococcygeal teratoma (SCT) in a fetus with distal 10q trisomy has not been reported yet. METHODS: A 33-year-old, G5, P2 woman with a singleton pregnancy was referred to our clinic at 24 weeks of gestation for further evaluation of a fetal sacral exophytic mass. Detailed fetal sonographic examination together with chromosomal analysis by amniocentesis was performed. RESULTS: The scan revealed a large SCT together with a persistent right umbilical vein, cardiomegaly, bilateral mild hydronephrosis and intrauterine growth retardation. The fetal karyotype showed distal 10q trisomy (10q24.3-->qter) distal monosomy 17 (p13-->pter). The fetus died after a preterm delivery at 28 weeks of gestation. Postnatal examination confirmed the prenatal findings and added the typical facial features of this syndrome, which consisted of prominent forehead, small nose with depressed nasal bridge, micrognathia and bow-shaped mouth. CONCLUSION: This case provides further evidence of a possible association between chromosomal aberrations in SCTs.

Isolated torsion of fallopian tube in a post-menopausal patient: a case report.

Isolated fallopian tube torsion after menopause is a rare condition. Here we report the second case of isolated fallopian tube torsion in a post-menopausal woman. A 55-year-old post-menopausal woman presented with right lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the right uterine border. Laparatomy revealed torsion of the right fallopian tube together with a paraovarian cyst. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathological examination revealed a simple paraovarian cyst with severe congestion, necrosis and hemorrhage. Tubal torsion should be considered in the differential diagnosis of acute lower abdominal pain, even in post-menopausal women.

Prenatal diagnosis of a fetus with partial trisomy 7p.

We report a prenatal diagnosis of a fetus with partial trisomy 7p. Ultrasonography at 28 weeks of gestation of a 27-year-old multigravid woman revealed a growth-retarded fetus with agenesis of the corpus callosum, enlarged left kidney, single umbilical artery, hypertelorism, depressed nasal bridge, frontal bossing, irregular maxiller alveolar composition, club feet, flexion deformity of the upper extremities and Epstein anomaly. Fetal karyotype was 46,XX,der(9)add(9p24),16qh+. Our results indicated that the fetus had an unbalanced translocation, which resulted in duplication of the proximal segment of 7p. Maternal karyotype was (46,XX,t(7,9)(p15.3,p24),16qh+). Because fetal death occurred at 31 weeks of gestation, induction of labor was performed. An enlarged anterior fontanel and micrognathia were seen during fetal autopsy. Trisomy 7p is related to a well-known clinical picture with a dismal prognosis. Our report showed that the outcome of the affected pregnancy may also be poor. Detection of fetal chromosomal abnormality and parental translocations are essential for counseling of the parents.

Surgical management of intra-abdominal mislocated intrauterine devices.

OBJECTIVE: We report on our experience in surgical treatment of patients with intra-abdominal intrauterine devices (IUDs). MATERIAL AND METHODS: A total of 10 patients were retrospectively analyzed. Diagnosis was based on gynecologic examination, transvaginal sonography, and abdominal X-ray. RESULTS: All of the IUDs were inserted by trained midwives, either in the puerperal period (n=3) or within 1 year after puerperium (n=7). Five women were asymptomatic at the time of diagnosis, three were pregnant and two complained of pelvic pain. Eight patients were managed by laparoscopy, whereas laparotomy was required in two. Abscess formation was present in two cases. The postoperative course was uneventful in all patients. CONCLUSION: A missing string during gynecologic examination is the first sign of an intra-abdominal IUD in all cases. Transvaginal sonography should be combined with abdominal X-ray to reach a definitive diagnosis. Laparoscopic treatment may be appropriate in most of the cases.