Prolonged early antenatal indomethacin exposure is safe for fetus and neonate.

Objective: To evaluate fetal and neonatal safety of early-onset long-term antenatal indomethacin treatment (LIT) for short cervix.Methods: In this cohort study, women started LIT for short cervix (<25 mm) before completing 25 weeks. They followed a standardized regiment of oral indomethacin: 100 mg loading, 50 mg qid for 48 h, 25 mg qid until delivery or at 32 weeks gestational age (GA), whichever comes first. Weekly monitoring for oligohydramnios and ductus arteriosus (DA) constriction included confirmation of compliance with treatment/dose. This approach is established in our clinical practice. To identify LIT complications separate from prematurity, each neonate exposed to LIT were matched to two unexposed neonatal controls within ±3 days of GA of delivery and birth weight of ±10%. Odds ratios for neonatal variables included pulmonary hemorrhage, patent DA (PDA) requiring medical or surgical correction, necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), intraventricular hemorrhage (IVH) grade III-IV, other intracranial hemorrhage (ICH), neonatal mortality, calculated individually, and for total composite morbidity. Statistical determinants of neonatal morbidity were assessed using binary logistic regression. Exposure to LIT, maternal age, parity, BMI, GA at delivery, birth-weight (BW), neonatal gender, cord artery pH, and 5-min Apgar score were independent variables.Results: 166 LIT cases were matched with 332 controls. LIT median duration was 49 (3-108) days. Mean delivery GA was 34 weeks. LIT was stopped for 5 patients (2.9%) with oligohydramnios and 1 (0.6%) with DA constriction, without consequent morbidity. 71 cases (43%) completed LIT, stopping at 32 weeks. 95 stopped early for preterm premature ruptures of membranes (PPROM) (20%), active labor (11%) or patient choice (22%). Odds of any individual complication did not differ between treated cases and controls. LIT was not a statistical determinant of composite morbidity or any individual neonatal problem.Conclusion: Continuous early-onset indomethacin exposure, up to 15 weeks antenatally, did not increase fetal or neonatal complications. This level of safety is permissive to a randomized trial of indomethacin for the treatment of short cervix.

The efficacy of transcutaneous electrical nerve stimulation therapy in pain control after cesarean section delivery associated with uterine contractions and abdominal incision.

OBJECTIVES: This study aims to investigate the effects of transcutaneous electrical nerve stimulation (TENS) therapy on the intensity of pain associated with uterine contractions and abdominal incision in patients undergoing cesarean section (C-section) delivery. PATIENTS AND METHODS: This single-blind, prospective, randomized-controlled study included a total of 90 female patients (mean age 30.5 years; range, 25 to 36 years) who had a scheduled C-section delivery between November 2017 and April 2018. Forty-five postpartum patients were randomly assigned into the treatment group (Group 1) and TENS electrodes were placed below and above the abdominal incision. The control group (n=45) consisted of 45 patients who had a scheduled C-section (Group 2) (n=45) and received routine follow-up care. The Visual Numeric Scale (VNS) scores were obtained separately for abdominal, low back, and groin pain at baseline (within 1 h after C-section before the TENS replacement), at postpartum 2, 6, 24, and 48 h. In addition to instant scoring, the percentages of change in pain scores from baseline were also calculated for each time points. RESULTS: Data of a total of 87 patients were analyzed. No statistically significant difference was found in the baseline VNS scores measured in any body regions between the groups (p>0.05). However, there was a statistically significant difference in the instant VNS scores for abdominal pain at 2, 6, 24, and 48 h in favor of Group 1 (p<0.05). No significant differences were found in the instant VNS scores for low back and groin pain (p>0.05). The comparison of changes in pain scores from baseline (% change) over time between the groups revealed a statistically significant difference in favor of Group 1 in all VNS scores for abdominal, low back, and groin pain at 2, 6, 24, and 48 h (p<0.05). CONCLUSION: Our study results suggest that TENS is an effective and safe non-invasive, non-pharmacological treatment modality. It may be preferred as an alternative method in pain control in postpartum women after C-section delivery.

Does antenatal magnesium sulphate improve hearing function in premature newborns?

Objective: To evaluate whether antenatal magnesium sulphate (MgSO4) exposure has a neuroprotective effect against hearing impairment in premature newborns. Material and Methods: Retrospective cohort study was performed with prematurely (<37 weeks) delivered newborns at a tertiary university hospital. Newborns of 92 women who received MgSO4 infusions (study group) for various indications were compared to newborns of 147 women who did not receive MgSO4 infusions (control group). All eligible premature newborn underwent hearing screening by auditory brainstem response (ABR) testing before being discharged from the hospital. Results: The fail rate for ABR hearing screening was 3.3% (n=3) in the study group and 10.9% (n=16) in the control group (p=0.034). The rate of concurrent use of betamethasone was higher in the study group (72.8%; n=67) compared to control group (29.2%; n=43) (p<0.001). Other neonatal parameters, such as the number of neonates who were small for gestational age and the rate of microcephaly were similar between the groups (p=0.54, p=0.48, respectively). After adjusting for co-variates including the use of betamethasone and gestational age at delivery, no statistically significant association between antenatal administration of MgSO4 and ABR fail rates were found (p=0.07). Conclusion: These results do not suggest a significant benefit in terms of hearing impairment in premature newborns when antenatal MgSO4 infusion was given.

Different treatment modalities and outcomes in cesarean scar pregnancy: a retrospective analysis of 31 cases in a university hospital.

OBJECTIVES: There is no standardized treatment modality or a generally accepted guideline in cesarean scar pregnancy (CSP) treatment. The aim of this study is to retrospectively evaluate the outcomes of the different treatment modalities used in CSP treatment. MATERIAL AND METHODS: 31 CSP patients retrospectively evaluated between May 2011 and February at Uludag University Hospital in Bursa, Turkey included in the study. A graphical flowchart according to the treatment modalities and timeline graphics of the patients were used. Main outcome measures were recurrent CSPs and healthy pregnancies in clinical follow-up after a successful CSP treatment. RESULTS: 31 CSP patients were treated with six different treatment modalities in our series. Recurrent CSP was diagnosed in three patients after a successful CSP treatment. All of these recurrent CSPs were treated with D/C procedure in their first CSP. Six patients conceived again in clinical follow-up after successful treatment of CSP. CONCLUSIONS: CSP is a serious maternal complication that risks the mother's life, and this problem is growing because of the increased cesarean rates. Invasive procedures applied to the uterus in CSP treatment may cause recurrent CSP in the next pregnancy of the patient. When considering the treatment options of the CSP, minimally invasive treatment modalities and the subsequent gestation of the patient should be taken into account.

Laparoscopic hysterectomy trends in challenging cases (1995-2018).

OBJECTIVE: To investigate the effect of challenging factors on laparoscopic hysterectomy trends within twenty-four years. POPULATION AND METHOD: This was a trend analysis study of 7558 women who underwent hysterectomy for benign indications between 1995-2018 in Bursa Uludag University Hospital, Turkey. A trend analysis of obesity, previous laparotomy (≥3) and uterine specimen weight (≥500g) was applied for abdominal hysterectomy (TAH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (TLH) rates in this period. The primary outcome was laparoscopic hysterectomy trends throughout the years. We measured the effect of obesity, previous laparotomies and large uterus on TLH trends as secondary outcomes. RESULTS: The ratio of TLHs to all hysterectomies was 2.4% in 1995 and 44.7% in 2018 which increased 33 times higher over 24 years. The percentage of obese patients in TLH cases increased from 1% to 37%, the rate of patients who had three or more previous laparotomy in TLH cases increased from 0% to 32.2%, and the percentage of patients who had more than 500g uterus specimen in laparoscopic hysterectomy cases increased from 0% to 32.8%. CONCLUSION: Laparoscopic hysterectomy trends are increasing in challenging cases. Obesity, previous surgeries, and large uteruses are no longer a limiting factor for laparoscopic hysterectomy.

Retrospective case series examining the clinical significance of subjective fetal cardiac ventricular disproportion.

OBJECTIVE: To evaluate fetal cardiac ventricular disproportion as a marker of cardiac anomalies. METHODS: A retrospective case series included data from all patients who had a fetus diagnosed subjectively with ventricular disproportion by routine obstetric ultrasonography between January 1, 2007 and December 31, 2013 at a single tertiary center in the USA. Fetal and neonatal echocardiography, and neonatal outcome data were retrieved. Outcomes were described for all fetuses with subjective ventricular disproportion. Then, the objective right-to-left ventricular ratio (RLVR) was calculated as a continuous (after transformation to gestational age specific z-scores) or categorical value (>2SD for gestational week), based on previously published reference values. Subsequently, correlations between the objective RLVR and neonatal outcomes were evaluated. RESULTS: Records from 60 fetuses diagnosed with ventricular disproportion at 16-38 weeks of gestation were included. These pregnancies resulted in 54 live deliveries; postnatally, 20 (37%) of these neonates were diagnosed with aortic coarctation and 39 (72%) were diagnosed with other cardiac anomalies, with or without aortic coarctation. No significant differences in objective prenatal diagnostic findings (RLVR) were demonstrated between neonates who were diagnosed postnatally with aortic coarctation or any cardiac anomaly and those not. CONCLUSION: Subjective ventricular disproportion, regardless of objective diagnosis, was associated with cardiac defects. The use of fetal and neonatal echocardiography following diagnosis of fetal ventricular disproportion appears justified.

Wilms' tumor 1 protein expression in endometrial adenocarcinoma and endometrial intra-epithelial neoplasia.

AIM: To investigate the expression of Wilms' tumor 1 (WT1) protein in endometrial adenocarcinoma (EC) and endometrial intra-epithelial neoplasia (EIN). METHODS: WT1 protein expression was determined on immunohistochemistry in 30 EC patients and in 20 EIN patients. WT1 protein expression in proliferative (n = 7), secretory (n = 9) and atrophic endometrium (n = 9) and benign endometrial polyps (n = 28) was used as the control group. Cellular and vascular WT1 staining was scored semiquantitatively. RESULTS: Cellular WT1 staining was 67% and vascular positivity was 73% in the EC group. In the EIN group the cellular staining was 100% and vascular staining was 85%. Although all EIN samples were positive for cellular WT1 staining, median cellular staining score was similar to that of EC (median, 2; range, 1-3; IQR, 1.75 vs 2, 0-3, 0.75, respectively). Increasing EC grade and stage were not associated with cellular or vascular WT1 staining score. CONCLUSION: WT1 is expressed in EIN.

Possible role of asymmetric dimethylarginine (ADMA) in prediction of perinatal outcome in preeclampsia and fetal growth retardation related to preeclampsia.

OBJECTIVE: The objective of this study is to investigate maternal serum and neonatal umbilical cord asymmetric dimethylarginine (ADMA) levels in prediction of perinatal prognosis in pregnancies with preeclampsia (PE) and fetal intrauterine growth retardation (IUGR) accompanying PE (PE + IUGR). METHODS: Maternal serum ADMA (msADMA) and neonatal umbilical cord ADMA (ucADMA) levels were studied from 34 patients with PE, 25 patients with PE + IUGR, and 30 healthy pregnant controls in this prospective case-control study. Umbilical artery Doppler indices of fetuses, birth weights, Apgar scores, umbilical artery pH measurements of neonates, and admissions to neonatal intensive care unit (NICU) were recorded. RESULTS: Median msADMA was significantly higher in PE and PE + IUGR groups (p = 0.024 and p = 0.011, respectively), and ucADMA was significantly higher in PE and PE + IUGR groups than the control group (p = 0.029 and p = 0.018, respectively). Median msADMA and ucADMA levels were significantly higher in the PE + IUGR group than the PE group (p = 0.019 and 0.021, respectively). ucADMA levels did not correlate with fetal umbilical arterial blood flow neither in the PE nor in the PE + IUGR group (p = 0.518 and p = 0.892, respectively). None was related with neonatal umbilical artery pH or NICU admission rates. CONCLUSIONS: msADMA and ucADMA correlated with severity of PE. msADMA and ucADMA failed to predict perinatal outcome in patients with PE and PE + IUGR.

What is the optimal strategy in the management of patients with preterm premature rupture of membranes before 32 weeks of gestation?

OBJECTIVE: Our aim was to compare the outcomes of expectant management of pregnancy or immediate delivery in patients with preterm premature rupture of membranes (PPROM) between 24+0 and 32+0 weeks of pregnancy. MATERIALS AND METHODS: This is a retrospective cohort study conducted at a tertiary medical center. Patients who were diagnosed as having PPROM between 24+0 and 32+0 weeks of gestation were selected from an electronic database. Thirty-one patients with expectant management and 22 patients with spontaneous immediate delivery were analyzed. Birth weight, Apgar score, duration of stay in the neonatal intensive care unit (NICU), composite adverse outcomes, and mortality rates of groups were compared. Binary logistic regression analysis with backward stepwise elimination was used to determine confounding factors for antenatal complications and neonatal composite adverse outcomes. RESULTS: Gestational age at admission was smaller in the expectant management group. The median latency period was 6 days (range, 2-58 days). Although gestational age at delivery was similar, birth weights were smaller in expectant management group compared with the immediate delivery group (p=0.264 and p<0.05, respectively). Apgar scores, duration in the NICU, composite adverse outcomes, and neonatal mortality rates were similar in each group. Antenatal complication in the expectant management group was higher (p<0.05). Gestational age at delivery and serum C-reactive protein levels were two confounding factors for antenatal complication and gestational age at delivery was the only factor affecting composite adverse outcome. CONCLUSION: Expectant management in patients with PPROM at 24 to 32 gestational weeks might be considered as a good alternative.

What should we do to optimise outcome in twin pregnancy complicated with placenta percreta? A case report.

BACKGROUND: Patients with morbidly adherent placenta (MAP) are under risk of massive bleeding. It readily necessitates very complicated surgery and massive blood transfusion, and even leads to mortality. Cesarean hysterectomy (CH) is the procedure that is acknowledged worldwide, since it helps to minimize complications. CASE PRESENTATION: A patient with dichorionic twin pregnancy underwent to cesarean section (CS) due to preliminary diagnosis of placenta percreta at her 35(th) week of pregnancy. Both of the placentas were left in situ. The patient admitted with signs of infection. Emergency total abdominal hysterectomy was performed 7 weeks after CS. In the course of hysterectomy, 3 units of erythrocyte suspension and 2 units of fresh frozen plasma were transferred, whereas none was required during CS. CONCLUSION: Abandoning placenta in situ seems to be a logical alternative to the CH in patients with placenta percreta in order to minimize complications related to massive blood transfusion and surgical technique. However, it appears to increase maternal morbidity due to maternal infection in twin pregnancy.

Cutaneous Fistulization of an Ovarian Mature Cystic Teratoma: An Unusual Occurrence.

A bilobulated mature cystic teratoma (MCT) at the left ovary measuring 6 cm in diameter fistulized to the left lower quadrant of the anterior abdominal wall, contralateral to McBurney's point. This is the first reported case of a MCT fistulized to the skin. Symptoms, if present, usually depend on the size of the teratoma. However, most patients with a MCT are asymptomatic. Complications such as rupture of the cyst capsule are quite rare. Moreover, complication of fistulization is highly infrequent.

Intrahepatic cholestasis of pregnancy: Relationship between bile acid levels and maternal and fetal complications.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) complicates pregnancies which is characterized by elevated serum bile acid levels. ICP increases maternal and fetal morbidities. This study was designed to determine the association of maternal and fetal complications and serum bile acid levels. MATERIAL AND METHOD: Maternal and fetal characteristics were analyzed from the medical records of 61 patients who gave birth following a pregnancy complicated with ICP between 2009 and 2013. RESULTS: Eighty seven percent of 61 cases were singletons, and 13% of them were twins. Mean SBA level was 36 µmol/L. Preterm birth rate among singletons and twin pregnancies were 24.5% and 62.5%, respectively. Mean SBA level in preterm birth group was statistically higher with respect to the term birth group (100.8 µmol/L and 25.61 µmol/L, respectively; p=0.001). No perinatal mortality associated with ICP was detected in the study group. CONCLUSION: Pregnant women with the ICP compose high-risk group in regard to fetal and maternal risks. Close follow-up of these patients is required due to increased risks such as preterm delivery, meconium staining and fetal death.

Effect of raloxifene and atorvastatin in atherosclerotic process in ovariectomized rats.

AIM: The goal of this study was to investigate the combined effects of raloxifene and atorvastatin in aged ovariectomized rats during endothelial dysfunction and atherosclerotic process. MATERIAL AND METHODS: This study was conducted on 28 Wistar albino female rats randomly divided into four groups. All groups were ovariectomized and one group was kept as the control group (OVX). For four weeks, the remaining three groups were treated with the statin atorvastatin (OVX+AV), the selective estrogen receptor modulator raloxifene (OVX+RL), and both atorvastatin and raloxifene (OVX+RL+AV), respectively. At the end of the treatment period, all rats were sacrificed and thoracic aortas excised, and endothelial cells were immunohistochemically stained for markers in the atherosclerotic process, such as inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS), endothelin-1 (ET-1), monocyte chemotactic protein-1 (MCP-1), and tumor necrosis factor alpha (TNF-α). RESULTS: Compared to the ovariectomized group, the iNOS level was significantly increased in the OVX+RL group (P=0.002), but contrarily decreased in the groups OVX+AV (P=0.002) and OVX+RL+AV (P=0.002). eNOS levels in the groups OVX+AV (P=0.002) and OVX+RL+AV (P=0.002) were significantly lower than that in the OVX group. When compared to the OVX group, significant reductions in ET-1 and TNF-α levels were found in all treatment groups. A significant decrement in MCP-1 level was found in the OVX+AV group (P=0.002). CONCLUSION: In aged ovariectomized rats, the administration of both raloxifene and atorvastatin significantly decreased the levels of ET-1 and TNF-α on endothelial cells. Combined treatment with these drugs shortly after menopause might play a potential preventive role in the early stages of atherosclerosis development.