Centile charts of cervical length in singleton and twin pregnancies between 16 and 24 weeks of gestation

Objective: The aim of this study was to determine the standard mid-trimester cervical lengths of singleton and twin pregnancies. Material and Methods: This study was conducted by retrospective analysis of mid-trimester transvaginal cervical measurements of women with singleton and twin pregnancies that were examined by a single perinatologist in a single center. Results: A total of 4621 consecutive asymptomatic pregnant women admitting for advanced obstetric ultrasound screening were evaluated. Of these 4340 (93.9%) were second trimester singleton pregnancies and 281 (6.1%) were twin pregnancies and were included. Mean cervical length measurements of singleton and twin pregnancies were 38.2±6.5 mm and 37.6±7.2 mm respectively (p=0.17). Overall, the 5th percentile of cervical length measurement after analysing singleton and twin pregnancies together was 29.4 mm at 16 weeks, 30 mm at 17 weeks, 30 mm at 18 weeks, 30 mm at 19 weeks, 30 mm at 20 weeks, 30 mm at 21 weeks, 30 mm at 22 weeks, 31 mm at 23 weeks, 29 mm at 24 weeks. Conclusion: In our population the 5th precentile value of cervical length which is 30 mm in singletons and 10th percentile cervical length which is 31 mm in twins can be used to follow-up and treat pregnant women at risk for preterm delivers.

Comparison of the localization of intrauterine adhesions in pregnant and infertile women.

Objective: Intrauterine adhesion (IUA) is the formation of band-shaped fibrotic tissues in the endometrial cavity due to uterine procedures. Most adhesions remain asymptomatic and do not affect fertility or pregnancy conditions. However, they may lead to infertility and pregnancy complications in some women. This study aimed to determine which localization and type of IUA may lead to infertility. Materials and Methods: Seventy-six women with IUA were retrospectively scanned. Thirty-nine women with IUA with uterine factor-related infertility were included in the infertility group. Thirty-seven pregnant women, who had adhesions in the second-trimester ultrasonography and who had a live birth via cesarean section at term, were included in the pregnancy group. The localization of adhesions was determined as the fundus, corpus, isthmus, and cornu. Concerning the type of adhesion, the adhesions were classified as dense- and film-type adhesions. Results: The infertility group was compared with the pregnancy group according to the type and localization of the adhesions. Fundal adhesions were significantly higher in the infertility group compared to the pregnancy group (p<0.05). The isthmic adhesions, however, were more common in the pregnancy group than in the infertility group (p<0.05). Dense-type adhesions were more common in the infertility group than in the pregnancy group (p<0.05). Conclusion: According to the localization and types of adhesions, fundal and dense-type adhesions are among the features of uterine factor-related infertility. However, isthmus-located and film-type adhesions may not cause infertility.

Obstetric hemorrhage and surgical emergencies training workshops on fresh cadavers and simulators result in high application in daily practices and decreased patient referral.

Objective: In this study, we aimed to evaluate the effects of obstetric emergencies workshops combining theoretical lectures, simulation trainers and fresh cadaver models on daily practices and referrals of obstetrics and gynecology specialists. Materials and Methods: This is a prospective observational study involving obstetrics and gynecology specialists attending the Turkish Society of Obstetrics and Gynecology endorsed obstetrics hemorrhage management courses held in 2018 and 2019. The training course is an annually organized two-day course, one day allotted to theoretical lectures and the other day to practical training on both simulators and fresh cadavers. Trainees participating in the course was surveyed with an anonymous questionnaire on their motivation to attend the course and their juridical history of obstetric patient management. Attendees were asked to disclose whether they had ever independently performed the procedures stated in the questionnaire or not, before commencing the course and 1 year after attending the course. Results: Among the attendees 22% (n=32) had at least one obstetrical malpractice lawsuit and 36.1% (n=52) were accused of Health Care Complaints Comission. The main motivation of the attendees for taking this course was Professional development followed by reducing maternal mortality and morbidity and avoiding malpractice. One year after the course, attendees applying uterine devascularization surgery increased by 36.1% (52/144), uterine compression sutures increased by 52.7% (76/144), and ability to apply uterine balloon tamponade increased by 59.7% (86/144). Besides improvement in other obstetric surgical skills an indirect effect seen that the attandees operated on high-risk cases increased in placenta previa (15.3%), placenta acreata spectrum (30.5%), operative deliveries (27.7%), peripartum hysterectomy (24.9%) and relaparotomy for postpartum hemorrhage (34.7%). Conclusion: Opportunities of attending well organized fresh cadaveric workshops on managing postpartum hemorrhage and other obstetric surgeries, can quickly adapt to daily practice, restore the professional confidence of obstetric and gynecology specialists, and eventually decrease patient referral.

A novel low uterine segment sandwich technique (Caliskan's technique) for the management of post-cesarean hemorrhage due to placenta previa accreta

Objective: Placenta previa (PP) and placenta accreta spectrum (PAS) disorders are major causes of postpartum hemorrhage (PPH). There is a variety of surgical management options with inexplicit reported success rates. Uterine sandwich is a combination of uterine compression sutures and intrauterine balloon placement to achieve hemostasis. The aim of this study was to present our experience of seven women managed with a novel "lower uterine sandwich" technique to control post-cesarean hemorrhage due to PP accreta. Materials and Methods: Seven pregnant women diagnosed as having PP totalis accreta underwent a post-cesarean procedure combining bilateral ligation of the uterine artery, utero-ovarian artery, and internal iliac artery, Pereira compression sutures implemented on the uterine isthmus, Foley catheter placement into the lower uterine segment, and transvaginal cervical cerclage application, namely "Caliskan's uterine sandwich technique". Results: All women included in this study had placental invasion abnormalities of varying degrees. Postoperative diffusion magnetic resonance imaging assessment revealed a completely normal and preserved uterine blood supply. All women menstruated regularly in their postoperative follow-up period and two women conceived again and delivered uneventfully. None of the patients experienced morbid complications nor required hysterectomy. Conclusion: This novel procedure appears to be a plausible fertility and organ-preserving option in cases of intractable PPH, particularly in lower uterine segment bleeding. This uterine sandwich technique may allow physicians to manage massive hemorrhage due to PAS conservatively by preserving the uterus and its functions without major complications.

Cervical cerclage application algorithm in continued cervical shortening cases despite vaginal progesterone.

OBJECTIVE: The aim of this study is evaluation of pregnancy outcomes of the asymptomatic cases with vaginal progesterone treatment for the 20-30 mm cervical length detected in the transvaginal ultrasonography for fetal abnormality screening and cervical cerclage after cervical length detected <20 mm in weekly cervical length measures; and present the treatment algorithm of progesterone treatment combined with cervical cerclage application. METHODS: Patients who have the inclusion criteria and cervical length more than 30 mm were categorized as group 1(n = 1948). Group 2 were included patients with cervical length shorter than 30 mm (n = 95). All patients of group 2 started to use vaginal natural progesterone 400 mg/day(n = 87). Pregnancies which progressed with cervical length above 20 mm were continued vaginal progesterone until 34. Gestational week and they were named as group 2A (n = 78). Cervical cerclage were applied to patients with cervical length below than 20 mm measured via transvaginal ultrasonography and they were categorized as group 2B (n = 9). RESULTS: Excluding 8 cases (8.42 %) which cervical cerclage were applied, 87 patients were administered vaginal progesterone and in 9 cases (10.34 %) cervical shortening were continued despite progesterone treatment. Four out of these nine cases (44.44 %) had cervical cerclage and their deliveries were delayed after 34 th gestational week. Vaginal progesterone treatment prevented cervical shortening in 89.66 % of patients who had cervical length between 20-30 mm and out of these patients. CONCLUSION: Cervical cerclage application algorithm in continued cervical shortening cases despite vaginal progesterone is beneficial to delay the delivery after 34 th gestational week and related to low complication rate.

Aspirin, low molecular weight heparin, or both in preventing pregnancy complications in women with recurrent pregnancy loss and factor V Leiden mutation.

Objective: The aim of this study was to compare the effects of low molecular weight heparin (LMWH), LMWH plus low dose aspirin, or low dose aspirin only on pregnancy outcomes in recurrent pregnancy loss (RPL) patients with factor V Leiden mutation (FVLM).Materials and methods: A total of 2764 RPL patients were evaluated in for the etiology of RPL. Mutations in factor V Leiden homozygous and heterozygous were determined. Subsequently, 196 of these patients were diagnosed with FVLM and included in the study; of these 174 completed the study. At the sixth week of gestation of subsequent pregnancy participants were randomly distributed into three groups. Group A (n = 61) was composed of patients with an oral dose of 100 mg aspirin daily, Group B (n = 59) consisted of patients using 40 mg enoxaparin and 100 mg orally aspirin daily, and Group C (n = 54) included patients using 40 mg enoxaparin daily during pregnancy.Results: Among the 174 patients who completed the study, the live birth and miscarriage rates were similar for the three groups (p = .843 and p = .694, respectively). There was no significant difference among the groups in rates of eclampsia, placental abruption, intrauterine fetal growth restriction and gestational diabetes mellitus. The number of preeclamptic patients was significantly higher in Group A than Groups B and C. The levels of preterm birth was significantly higher in Group A than Groups B and C.Conclusion: Using low dose aspirin, LMWH plus aspirin, or LMWH alone yielded comparable live birth rates in RPL patients with FVLM. However, LMWH decreased the risk of preeclampsia in this group of patients. LMWH might therefore have a preventive role regarding preeclampsia.

Pelvic lymphadenectomy: Step-by-step surgical education video

Pelvic lymph node dissection is one of the leading surgical procedures in gynecologic oncology practice. Learning the proper technique with anatomic landmarks will improve surgical skills and confidence. This video demonstrates a right-side systematic pelvic lymphadenectomy in a cadaveric model.

Step-by-step ligation of the internal iliac artery

The internal iliac artery is the main vascular supply of pelvic visceral structures. All pelvic surgeons must know the anatomic landmarks and basic steps of internal iliac artery ligation in order to stop massive pelvic hemorrhage. This cadaveric demonstration and clinical review of the internal iliac artery shows the anatomic landmarks and basic steps of internal iliac artery ligation.

Comparative surgical resection of the ligamentum teres hepatis in a cadaveric model and a patient with ovarian cancer

Resection of all tumor implants with the aim of maximal cytoreduction is the main predictor of overall survival in ovarian carcinoma. However, there are high risk sites of tumor recurrence, and the perihepatic region, especially the point where the ligamentum teres hepatis enters the liver parenchyma under the hepatic bridge (pont hepatique), is one of them. This video demonstrates the resection of the ligamentum teres hepatis both in a cadaveric model and in a patient with ovarian cancer.

Uterine rupture in pregnancy subsequent to hysteroscopic surgery: A case series.

Uterine rupture during pregnancy is associated with high mortality and morbidity rates in both the fetus and the mother. Hysteroscopic surgeries such as myomectomy and septum resection are known risk factors for uterine rupture in pregnancy following the operation. We present four infertile patients who were admitted to Kocaeli Medical Park Hospital between February 2014 and November 2016. Three of the patients underwent hysteroscopic septum resection without complication and one had hysteroscopic myomectomy and a 7-8 mm sized rupture was detected. All of the patients became pregnant in less than a year after the operations. The first three patients had uterine rupture at 22nd, 38th, and 10th week, which is the earliest rupture in the literature. The last patient had an uneventful pregnancy and the rupture was observed during cesarean section. A short interval between hysteroscopy and pregnancy may increase the risk of rupture. It may be possible to become pregnant despite rupture and not have any problems during the entire pregnancy.

The effect of childhood cancer therapy on ovarian reserve and pubertal development.

The effects of childhood cancer therapy on ovarian reserve tests and on pubertal development within 5 years were compared with a control group. The study group was composed of 41 patients who underwent chemotherapy during pre-menarche (subgroup A; n = 15) and after menarche (subgroup B; n = 26); the control group was composed of 44 patients admitted with non-cancer related diseases (in total n = 85). Mean total ovarian volume and total antral follicle counts on ultrasound examination were significantly lower in the study group compared with the control group (3.5 ± 2.3 versus 5.2 ± 2.4 ml; P = 0.001; and 3.4 ± 3.3 versus 8.6 ± 3.5; P < 0.001, respectively). Mean FSH level was significantly higher in the study group (13.5 ± 16.2 versus 7.3 ± 2.7 mIU/ml; P = 0.017). Anti-Müllerian hormone levels in subgroup A were significantly higher than in subgroup B (1.8 ± 0.1 versus 1.5 ± 0.08 pg/dl; P = 0.034). In conclusion ovarian volume, antral follicle count and FSH can be used for evaluating the harmful effect of cancer chemotherapy on ovarian follicles. Post-menarche, Anti-Müllerian values reveal that ovarian follicles are more sensitive to the devastating effects of cytotoxic treatment.

Spontaneous rupture of uterine vein in twin pregnancy.

Objective. Aim of our study is to present a case of a twin pregnancy following invitro fertilization cycle complicated with hemoperitoneum at third trimester. Case. A 26-year-old nulliparous pregnant woman at 32 weeks of gestation with twin pregnancy following invitro fertilization cycle complained of abdominal pain. After 48 hours of admission, laparotomy was performed with indications of aggravated abdominal pain and decreased hemoglobin levels. Utero-ovarian vein branch rupture was detected on the right posterior side of uterus and bleeding was stopped by suturing the vein. Etiopathogenesis of the present case still remains unclear. Conclusion. Spontaneous rupture of the uterine vessels during pregnancy is a rare complication and may lead to maternal and fetal morbidity and mortality. Diagnosis and treatment are based on the clinical symptoms of acute abdominal pain and laboratory tests of hypovolemic shock signs.