Iodine status of pregnant women in a metropolitan city which proved to be an iodine-sufficient area. Is mandatory salt iodisation enough for pregnant women?

The objective of this study was to assess the iodine status of pregnant women in a metropolitan city which was stated as iodine sufficient area after salt iodination program. This multicenter, cross-sectional study was carried out on 3543 pregnant women. Age, gestational weeks, smoking, consumption of iodized salt, dietary salt restriction, history of stillbirth, abortus and congenital malformations were questioned. Spot urine samples were analyzed for urine iodine concentration (UIC). The outcomes were: (a) median UIC in three trimesters of pregnancy and (b) frequency of ID among pregnant women. The median UIC was 73 µg/L. The median UIC was 77 µg/L (1-324), 73 µg/L (1-600) and 70 µg/L (1-1650) in three trimesters of pregnancy, respectively (p: 0.14). UIC <50 µg/L was observed in 36.6% (n: 1295) and UIC<150 µg/L was observed in 90.7% (n: 3214) of pregnant women. Only 1% (n: 34) of the pregnant women had UIC levels higher than 500 µg/L. This study showed that more than 90% of the pregnant women in this iodine-sufficient city are facing some degree of iodine deficiency during their pregnancy. A salt iodization program might be satisfactory for the non-pregnant population, but it seems to be insufficient for the pregnant population.

Effect of parity on first-trimester uterine artery Doppler indices and their predictive value for pregnancy complications.

AIM: To investigate the relationship between parity and first-trimester uterine artery Doppler indices and determine their predictive value for pregnancy complications. METHODS: In 679 singleton pregnancies (388 parous and 291 nulliparous) attending for routine care at 11-14 weeks of gestation, we recorded maternal characteristics, medical and obstetric history, the presence of protodiastolic notching and measured uterine artery resistance index (RI). RESULTS: Parous women had a lower prevalence of bilateral notches (64 vs. 77.6%; p = 0.0002), median level of RI did not show any significant difference. In parous cases complicated with pregnancy-induced hypertension (PIH) (0.78 vs. 0.70; p = 0.0003) or miscarriage (0.86 vs. 0.71; p = 0.0003) mean levels of RI were significantly higher than in the nulliparous cases. By using mean RI we could predict the cases with PIH (area under curve (AUC) 0.63; p = 0.012), early PIH (AUC 0.84; p < 0.0001) and miscarriage (AUC 0.87; p < 0.0001) in the group of parous women. CONCLUSION: Parity has a significant effect on uterine artery Doppler findings in the first trimester of pregnancy. In the group of parous women the mean level of RI had a higher predictive value for miscarriage, early PIH and PIH.

First trimester maternal serum pregnancy-associated plasma protein-A is a predictive factor for early preterm delivery in normotensive pregnancies.

In this study, we investigated whether the concentrations of pregnancy-associated plasma protein-A (PAPP-A) or free ß-hCG (fßhCG) in the first trimester can identify women at increased risk of subsequent preterm delivery in the absence of hypertensive disorders. Preterm and early preterm deliveries are defined as those deliveries before completing 37 and 34 weeks, respectively. A total of 868 women were enrolled into this study. According to the level of the markers, the patients were evaluated in three groups: 1 - maternal serum level ≤ 5 th percentile, 2 - between 5th and 95th percentiles, 3 - ≥ 95 th percentile. In the group of patients with a PAPP-A level ≤ 5 th percentile [≤ 0.35 multiples of the median (MoM)], mean gestational age (GA) at delivery, mean birth weight and the number of the cases with early preterm delivery were significantly lower than the others. Mean level of PAPP-A was significantly lower in cases with early preterm than term deliveries (0.58 ± 0.32 versus 1.09 ± 0.69; p = 0.01). Maternal serum level of fßhCG did not show significant difference between these groups (0.84 ± 0.45 versus 1.17 ± 0.77; p = 0.15). Low levels of maternal serum PAPP-A (≤ 0.35 MoM) (Odds ratio = 7; 95% confidence interval 1.8-27.7; p = 0.0048) significantly predicted early preterm delivery in normotensive pregnancies. Women with low levels of PAPP-A at first trimester have a higher risk of early preterm delivery even in the absence of hypertensive disorders.

Different phenotypes of polycystic ovary syndrome in Turkish women: clinical and endocrine characteristics.

This study presents the differences in clinical, endocrine and metabolic parameters among different polycystic ovary syndrome (PCOS) phenotypes in Turkish women. Four hundred and ten women with PCOS were evaluated, while 97 healthy women served as controls. PCOS were defined by oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovaries on ultrasound (PCO). Patients were subdivided into four phenotypes: OA + HA + PCO (phenotype 1), OA + HA (phenotype 2), HA + PCO (phenotype 3), OA + PCO (phenotype 4). Phenotypes 1-4 were present in 47.1%, 13.2%, 21.2% and 18.5% of patients, respectively. They were also divided into three groups according to the BMI (<25 kg/m(2); 25≤ and ≤30 kg/m(2); and >30 kg/m(2)). ANOVA and Tukey post-hoc HSD tests were used. The LH levels and LH/FSH ratio were higher in phenotype 1 and 2 than phenotype 3. The LDL-C levels were higher in women with phenotype 1 and 4 than in women with phenotype 2. Women with BMI <25 kg/m(2) had higher levels of LH, LH/FSH ratio, and the HDL-C than other two groups. The levels of TG, LDL, fasting insulin and HOMA-IR increased with increasing BMI in four phenotypes. Results suggest that obesity seems to be the primary cause of metabolic disturbances in PCOS women.

Vaginal leiomyoma in pregnancy presenting as a prolapsed vaginal mass.

Vaginal leiomyomas are rare benign solid tumours of the vagina. They can cause mechanical dystocia, which is a common problem in obstetrics leading to serious maternal and perinatal complications. Here we describe a patient with a vaginal leiomyoma diagnosed during the mid-trimester that could have caused dystocia. This 22-year-old woman presented with a vaginal mass and leaking vaginal fluid during pregnancy. On examination, a prolapsed, pedunculated mass, measuring 5 × 3 × 4 cm was detected in the anterior vaginal wall. Via a midline incision, the mass was easily enucleated and removed. Transvaginal surgical enucleation of the vaginal leiomyoma is usually curative and recommended as the initial treatment of choice to prevent for dystocia. Such treatment is indicated when the tumour is a potential obstacle to normal labour.

Correlation between first-trimester maternal serum markers, second-trimester uterine artery doppler indices and pregnancy outcome.

AIMS: The aim of this study was to assess the correlation between first trimester maternal serum free beta-human chorionic gonadotropin (fBHCG), pregnancy-associated plasma protein A (PAPPA), second-trimester uterine artery (UA) Doppler measurements and adverse pregnancy outcomes. METHODS: Serum levels of PAPPA and fBHCG were determined at the first trimester, and patients underwent bilateral UA Doppler assessments at 20-25 weeks of gestation. A serum PAPPA level <0.4 MoM was termed as low and the abnormal Doppler findings were the presence of bilateral notches and RI >0.52 (mean) or unilateral notch and RI >0.66 (90th percentile). RESULTS: Mean PAPPA level was significantly lower in cases with unilateral or bilateral notches (1.09; 0.79 and 0.80 MoM for 0, 1 and 2 notches, p < 0.001). Fifty-two cases (12.8%) had a low PAPPA level; in this group the incidence of abnormal Doppler was significantly higher (34.6 vs. 18.4%, p = 0.011). In the presence of abnormal Doppler in a case with a low serum PAPPA the risk of pregnancy-induced hypertension (OR = 4.56, p = 0.0067), low birth weight (OR = 6.8, p = 0.0002) and the risk of at least one complication (OR = 7.6, p = 0.00001) were significantly high. CONCLUSION: Combination of first- and second-trimester findings might improve the efficiency of screening for pregnancy complications.

Vaginal Schwannoma in a case with uterine myoma.

Only 1% of gynecological neoplasms are vaginal, and mesenchymal tumors constitute only 2% of vaginal neoplasms. The most common form is leiomyomas. Schwannomas arise from the peripheral nerve sheath. We report a case of vaginal schwannoma associated with uterine myoma. A 52-year-old woman presented with lower abdominal pain and menorrhagia for a duration of 6 months. At sonographic examination, the patient was found to have uterine myomas and a solid mass measuring 5x4.5 cm beneath the vaginal wall. At laparotomy, the uterus with myoma was removed using our standard operation procedures. Surgical excision of the mass from vaginal aspect was also undertaken, and the histology demonstrated schwannoma. The tumor cells were vimentin (+), desmin (-), smooth muscle alpha-actin (-), HMB-45 (-), MART-1 (-) and S-100 (+). There is no evidence of recurrence during 6 months follow-up. The differential diagnosis of a mass in the vagina includes also schwannomas. Immunocytochemical labeling of the tumor cells is essential. Simple resection of the mass is the preferred method of treatment.

Antenatal Bartter syndrome: analysis of two cases with placental findings.

The prenatal diagnosis of Bartter syndrome can be based on the high chloride level in the amniotic fluid. Microscopic examination of the placenta in untreated cases showed extensive mineralization in the chorionic villi in previous studies. Two cases were presented at 26-29 weeks of gestation with severe polyhydramnios. The mothers were treated with Indomethacin, KCl, and serial amniocentesis in order to reduce the amniotic fluid volume and prevent fetal hypokalemia. The microscopic examination of the placenta revealed focal calcification and acute atherosis in placental vessels. The treatment with Indomethacin in the antenatal period can prevent severe nephrocalcinosis.

Sonographically diagnosed vault hematomas following vaginal hysterectomy and its correlation with postoperative morbidity.

OBJECTIVE: Our aim is to investigate sonographically detectable vault hematomas after vaginal hysterectomy and its relation to postoperative morbidity. METHODS: We studied a group of 103 women who had undergone vaginal hysterectomy for benign causes apart from uterovaginal prolapse. Transabdominal ultrasound examinations were carried out 24 to 72 hours after surgery to assess the presence of vault hematomas. Ultrasound findings were correlated with clinical data and postoperative morbidity. RESULTS: The incidence of vault hematoma was found 19.4% in present study. In these patients, 40% (8/20) had fever while only 2.4% (2/83) of cases without vault hematoma suffered from fever. Out of all women having vault hematoma, 70% (14/20) had small-sized hematoma and 30% (6/20) had large-sized hematoma. Fifty percent of patients (3/6) with large-sized hematoma, as compared to only 35% (5/14) with small-sized hematoma, suffered from febrile morbidity. Large-sized hematomas drained by vaginally, while all small-sized pelvic hematomas managed by watchful expectancy successfully. The significant difference was found mean hemoglobin drop and postoperative stay in the hematoma group or without hematoma group. CONCLUSION: Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Though febrile morbidity was more in cases with vault hematoma, the number of such patients was too small to be significant. Vaginal ultrasound examination should not be performed routinely after hysterectomy.

Semilobar holoprosencephaly with associated cyclopia and radial aplasia: first trimester diagnosis by means of integrating 2D-3D ultrasound.

INTRODUCTION: Holoprosencephaly (HPE) is commonly associated with facial malformations. We present a case of semilobar HPE associated with distal limb defect which was detected at 12 weeks of gestation. CASE: The fetus had a crown-rump length of 60 mm (12 weeks-4 days), had nuchal translucency thickness of 1.5 mm. Initial two-dimensional (2D) ultrasound revealed the absence of nasal bone, decreased BPD and abnormal profile. Transvaginal 2D ultrasound was effective in the detection of HPE (partially absence of the interhemispheric fissure, fused thalami, the choroid plexuses were not visualized bilateraly: absent 'butterfly' sign), cylopia, absence of the nose and unilateral radial aplasia. Three dimensional (3D) ultrasound provided a better visualization of the associated anomalies. The necropsy result confirmed the sonographic findings: the diagnosis was semilobar HPE, cyclopia, absence of the nose, and the absence of the radius and the thumb in the left arm. DISCUSSION: Transvaginal 2D sonographic examination is effective in detection of the cases with HPE at first trimester. Fetal morphological study through 3D ultrasound may facilitate the diagnosis of associated anomalies.

A new metabolic scoring system for analyzing the risk of hypertensive disorders of pregnancy.

OBJECTIVE: The aim of this study was to investigate the relationship between some components of metabolic syndrome (MS) and pregnancy induced hypertension (PIH). STUDY DESIGN: Forty-one patients with PIH (gestational hypertension or preeclampsia) after 32 weeks of gestation were compared with 97 normotensive pregnant women. Metabolic scores (0-4) were created using standard deviations in normotensive cases: mean level + 1SD for BMI (>31 kg/m(2)), mean level + 1SD for triglyceride (>287 mg/dl), mean level + 1SD for fasting serum glucose (>90 mg/dl)) and mean level - 1SD for HDL (<48 mg/dl). RESULTS: The mean values for BMI (31.6 +/- 5.7 vs. 27.7 +/- 3.6; P < 0.0001), fasting triglyceride (341 +/- 129 vs. 220.7 +/- 67; P < 0.0001) and glucose (87.5 +/- 17.1 vs. 79.6 +/- 10.4; P = 0.0009) were higher in hypertensive group. The proportions of the women with a positive result for each of the components were significantly higher in the group of PIH. The percentage of the cases having 2 (35.2 vs. 8.2%; P = 0.0002) and 3 or more (27 vs. 4.1%; P = 0.0003) components of MS was higher in the hypertensive group and the percentage of the cases with none of these factors was high in the normotensive group (10.8 vs. 56.7%; P < 0.0001). CONCLUSION: The presence of multiple components of MS may be a risk factor in the development of PIH. New scoring systems according to the gestational age might be useful in analyzing the risk of PIH.

Sonographic findings in adnexal torsion: a report of 34 cases.

OBJECTIVE: The aim of this study was to correlate the preoperative sonographic findings and operation type in cases with surgically proven adnexal torsion in our clinic. STUDY DESIGN: This retrospective study included 34 postmenarchal patients with adnexal torsion who were examined with ultrasound and then operated between November 2003 and October 2007. Surgical procedures performed were divided into two groups: (1) detorsion followed by aspiration or detorsion combined with resection of the adnexal cyst, (2) resection of the whole adnexa. Patients with additional adnexal pathologies as a cause of adnexal torsion were excluded from the study. RESULTS: Twenty-four out of 34 patients (71%) were treated with ovarian conservation and 10 (29%) with resection of the adnexa. Echogenic features of lesions identified in both patient subgroups were similar in appearance. The lowest resection rate was in the group with multicystic appearance (14%), and the highest in solid-cystic group (44.4%). The average mass size was not significantly different between resection (69.3 vs 86.1 mm) and conservation groups. The risk of adnexal resection was higher in cases with an adnexal mass larger than 60 mm (sensitivity 90%, specificity 54.1%) (P = 0.031). The blood flow was present in six of the 21 cases (28.5%). The number of cases who were treated with adnexal resection were significantly more in the group with absent blood flow (P = 0.045). CONCLUSION: Determination of preoperative sonographic appearance of the mass may be valuable, but it is not specific in the prediction of the operation type of the cases with adnexal torsion. The measurement of the diameter and assessment of blood flow in the adnexal mass might be helpful in detection of the cases who have high risk of adnexal resection.

Verrucous carcinoma of the cervix in a case with uterine prolapse.

Verrucous carcinoma of the female tract is rare. We present a case involving association of verrucous carcinoma of the cervix with uterine prolapse. A 86-year-old woman was admitted with postmenopausal vaginal bleeding. The gynecologic examination revealed the uterine prolapse with a exophytic tumorous mass (3 x 6 x 8 cm) on the cervix. A punch biopsy was taken from the tumor, which revealed coilocytotic and mild dysplastic changes in the squamous epithelium; invasion of the underlying stroma could not be evaluated. A cervical swab was tested for human papillomavirus (HPV) DNA using the polymerase chain reaction, and HPV type 31 was detected. The tumorous mass was totally excised. The histopathologic diagnosis was consistent with verrucous carcinoma of the cervix: exophytic lesion was composed of thickened, acanthotic papillary squamous epithelium with mild dysplasia and diffuse parakeratosis, and no obvious invasion was observed. The patient was periodically controlled by pelvic examination and was free of progressive disease at 6 months. The diagnosis and treatment of verrucous carcinoma of the cervix may be difficult in some cases. The presence of HPV type 31 in our case might indicate the possibility that HPV is the etiology of this neoplasm.

Screening properties of human papillomavirus testing for predicting cervical intraepithelial neoplasia in atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion smears: a prospective study.

The aim of the present study was to determine the usefulness of human papillomavirus (HPV) testing for predicting cervical intraepithelial neoplasia (CIN) 1 and 2 to 3 on cervical biopsies in women who had atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) on Papanicolaou tests. In this prospective cohort, 167 women with abnormal cytologic examination (ASCUS and LSIL) were evaluated by colposcopy-directed biopsy and endocervical curettage. Colposcopy was performed on all study participants to obtain cervical tissue for histologic examination for detection of underlying CIN in patients with an initial cytologic test result of ASCUS and LSIL. A sample for HPV DNA detection by polymerase chain reaction was obtained. The HPV type 16 was positive in 35.4% of the 167 women with abnormal cytologic examination result in our gynecologic outpatient's clinic. Histologic diagnosis of CIN 1 was found in 45 of 135 women with ASCUS and in 17 of 32 women with LSIL. According to the cytologic findings, the frequency of CIN grade 2 or 3 in patients classified as ASCUS and LSIL was 12.5% (17/135) and 18.7% (6/32), respectively. Of the ASCUS smears, 9.6% were positive for HPV type 16. The sensitivity of the HPV type 16 using polymerase chain reaction technique threshold in detecting CIN 1 and CIN 2 to 3 was 57% and 46% in ASCUS-LSIL cytologic examination, respectively. The positive predictive value of HPV type 16 ranged from 60% in patients with CIN 1 and 42% in CIN 2 to 3 in ASCUS-LSIL. By contrast, negative predictive value was 58% in patients with CIN 1 and 80% in CIN 2 to 3. The low positive predictive value of HPV testing with ASCUS smears suggests that HPV positivity could be not used for predicting the presence of CIN 2 to 3.

Maternal death after uterine rupture in an unscarred uterus: a case report.

Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the Emergency Department. Emergency Physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a multigravid woman who had a spontaneous uterine rupture after induction with oxytocin, followed by a discussion of uterine rupture with special emphasis on the unscarred uterus. After the delivery, the patient was treated with fundal pressure and oxytocin due to severe vaginal hemorrhage. Despite the lack of vaginal hemorrhage after 1 h, the condition of the patient worsened. Laparotomy and a hysterectomy were performed. A parametrial hematoma about 20 cm was detected. The patient died 30 min after the operation. The treatment for intrapartum uterine rupture includes fluid resuscitation and emergency laparotomy.

Maternal plasma fibronectin and advanced oxidative protein products for the prediction of preeclampsia in high risk pregnancies: a prospective cohort study.

OBJECTIVE: To determine whether maternal plasma fibronectin and advanced oxidative protein products (AOPP) can be used for the prediction of preeclampsia in high-risk women. STUDY DESIGN: One hundred pregnant women at high risk of preeclampsia were enrolled in this prospective cohort study. Maternal plasma total fibronectin and AOPP levels were measured at 19-25 weeks of gestation. AOPP levels were also measured in 23 normal non-pregnant women. After delivery, the pregnant cohort was assigned to either the normotensive or preeclamptic group depending on their clinical course. RESULTS: Among the 78 pregnant women who completed the study, 19 (24.3%) developed preeclampsia between 36 and 39 (36.8 +/- 1.0) weeks of gestation. AOPP levels, which are significantly higher in normotensive pregnant women compared to nonpregnant controls (42.55 +/- 15.94 vs. 27.95 +/- 10.5; p = 0.0001) were not significantly different between normotensive and preeclamptic women (42.55 +/- 15.94 vs. 47.45 +/- 14.19 microM; p = 0.23). Plasma fibronectin levels were significantly higher in women who continued to develop preeclampsia rather than remain normotensive (383.68 +/- 19.07 vs. 227.65 +/- 97.39; p < 0.0001). ROC curve analysis shows that total fibronectin >or=360 mg/l is predictive for the development of preeclampsia. The sensitivity, specificity, positive and negative predictive values are 57, 92, 73 and 85%, respectively, with a likelihood ratio of 7.38. CONCLUSION: Second trimester plasma concentrations of AOPP are not altered in women that develop pre-eclampsia later in pregnancy. However, total fibronectin levels are significantly increased and may be used to predict the onset of clinical symptoms of preeclampsia.

Comparison of the effects of the levonorgestrel-releasing intrauterine system (Mirena) and depot-medroxyprogesterone acetate (Depo-Provera) on subendometrial microvascularisation and uterine artery blood flow.

OBJECTIVE: To compare the effects of the levonorgestrel-intrauterine system (LNG-IUS) and depot-medroxyprogesterone acetate (DMPA) on subendometrial vascularisation and uterine artery blood flow. STUDY DESIGN: The trial compared 25 patients wearing a LNG-IUS and 25 patients receiving DMPA. The subendometrial blood flow was evaluated using power Doppler analysis; the pulsatility index (PI) and resistance index (RI) in the uterine artery and spiral arteries were evaluated with spectral Doppler. RESULTS: The PI and RI of the uterine artery and endometrial thickness did not differ significantly between the two groups. The subendometrial vascularisation was lower and the PI in the spiral arteries was higher in DMPA-users. CONCLUSION: In spite of a similar prevalence of bleeding disturbances, the effects of DMPA and the LNG-IUS on the subendometrial microvascularisation differ.

Association of psoriasis and vulval fibroepithelial polyp: first reported case.

Fibroepithelial stromal polyps of the vulvovaginal region display a wide range of morphologic appearances. This morphologic spectrum allows the correct diagnosis to be made in some cases but when histology reveals unusual features, the lesion may be misinterpreted as malignant. We present a case of a 35-year-old woman with psoriasis who developed a 15-cm polypoid lesion localized in the left labium. The labial lesion was resected and no recurrence was detected 12 months after the initial treatment. Histologically, the lesion exhibited the characteristics of a fibroepithelial stromal polyp with focal myxoid areas and underlying vulval psoriasis disease. The clinical, microscopic, and immunohistochemical findings of this case suggest a fibroepithelial polyp of the vulva. This vulval lesion represents a unique example of giant fibroepithelial stromal polyp developed in association with psoriasis.

Haemostasis after cold-knife conisation: a randomised prospective trial comparing cerclage suture versus electro-cauterization.

AIMS: The purpose of this study was to compare two different techniques of obtaining haemostasis after cold-knife conisation. METHODS: Seventy-eight women who required conisation for treatment of cervical intraepithelial neoplasia were prospectively enrolled in a randomised clinical trial to receive either cerclage with cold-knife conisation or cautery with cold-knife conisation. Outcome measures evaluated include estimated blood loss, operative time, early late haemorrhage and dysmenorrhoea. The short- and long-term morbidity was compared, and a six-month follow up was completed. RESULTS: The procedure-related complication rate was 16.7% in the cautery group, compared with 7.0% in the suture group (P < 0.05). The cerclage group had significantly shorter operative time and intraoperative blood loss than the cautery group (P < 0.05). Postoperative bleeding and dysmenorrhoea were observed in eight (10.2%), and 14 cases (17.9%), in cerclage and cautery group, respectively. Three cases (3.8%) had postoperative infections and were cured with oral antibiotics. CONCLUSIONS: These results suggest that cerclage suturing technique provided excellent haemostasis and restoration of normal cervical anatomy. Cerclage suture of the cone bed is superior to only cauterization as a method of achieving haemostasis, with significantly less blood loss and shorter operative time.

Imperforate hymen-a rare cause of abdominal pain: two cases and review of the literature.

STUDY OBJECTIVE: To document an unusual cause of abdominal pain in premenarcheal adolescent girls. DESIGN: Case report. SETTING: A training and research hospital in Istanbul. RESULTS: Two cases of hematocolpos in two adolescent girls due to imperforate hymen were reported. Both of them manifested lower abdominal pain and urinary retention. Hymenotomy was performed in both the cases. CONCLUSION: Imperforate hymen is a rare diagnosis, but should be considered when dealing with premenarcheal adolescent girls with lower abdominal symptoms or back pain.