Effectiveness of segmental resection technique in the treatment of placenta accreta spectrum.

BACKGROUND: Placental accreta is a serious obstetrical entity and its management is challenging. The aim of this study was to evaluate and define our uterus sparing surgical technique in patients with placenta accreta spectrum. METHODS: The data of 21 patients who underwent uterine segmental resection during cesarean section with a preliminary diagnosis of placenta accreta spectrum at Ege University between January 2017 and December 2018 were evaluated retrospectively. RESULTS: Twenty-one patients were successfully treated with the segmental resection technique. In all cases, resected tissues were evaluated by histopathologically and the diagnosis of placenta accreta spectrum was confirmed. Hysterectomy was performed in two cases due to peri-partum hemorrhage that disrupted hemodynamics. None of the patients had complications such as visceral organ injury and wound infection. CONCLUSION: Our technique of uterine sparing surgery seems to be safe and effective in the management of placenta accreta spectrum without increasing complication rates.

Exenatide preserves trabecular bone microarchitecture in experimental ovariectomized rat model.

PURPOSE: The aim of this study is to investigate effects of exenatide (Glucagon-Like Peptide Agonist) replacement on bone mineral density (BMD) and microarchitecture in a surgical menopause-induced osteoporosis model in rats. METHODS: In this study, 24 female Sprague-Dawley albino mature rats were used. Rats were assigned either to the group ovariectomized administered exenatide or to the control group. Bone Mineral Density (BMD), plasma cytokine levels and histomorphometric analysis were measured. RESULTS: Ovariectomized rats showed significant decrease BMD values, trabecular counts, trabecular thickness and trabecular area. Also, significant increase trabecular separation and plasma TNF-α (Tumor Necrosis Factor) and IL-6 (Interleukin) levels. Exenatide treatment reversed these changes and it showed a considerable protective effect on trabecular bone microarchitecture. CONCLUSIONS: Exenatide may be a candidate for use in the treatment of postmenopausal osteoporosis and anti-inflammatory properties can be attributed this effects.

Iatrogenic uterine perforation and bowel penetration using a Hohlmanipulator: A case report.

INTRODUCTION: Adequate exposure is a vital factor in total laparoscopic hysterectomy, and uterine manipulators have been used in achieving that. The Hohl uterine manipulator has been considered to be one of the safer manipulators. Beside adequate exposure, it is associated with lower intraoperative complications. However, we report a case of iatrogenic uterine rupture with the Hohl manipulator which also caused bowel penetration. PRESENTATION OF CASE: A 52-year-old woman with endometrial hyperplasia was scheduled for total laparoscopic hysterectomy. Prior to entering into the abdomen, the Hohl uterine manipulator was introduced into the uterine cavity without force. During the laparoscopic exploration, we noted that the tip of the Hohl manipulator had perforated the posterior uterine fundus and penetrated the bowel. Therefore, laparotomy was performed, and the bowel injury was repaired by a colorectal surgeon. DISCUSSION: The Hohl uterine manipulator is safe and easy to use, and is associated with decreased intraoperative injuries. However, the complications observed due to the improper use of an uterine manipulator can overshadow any advantages of manipulator. In the present report, we describe a case of uterine perforation and bowel penetration caused by the Hohl uterine manipulator during total laparoscopic hysterectomy, which required conversion to laparotomy. The cause for this complication is associated with improper usage of the uterine manipulator. CONCLUSION: Uterine manipulator may cause uterine perforation and bowel penetration at the beginning of the hysterectomy procedure. These types of complications can be prevented by proper application of the Hohl manipulator into the uterus under direct pelvic visualization.

How quickly can acute symptomatic hyponatremia be corrected?

The systemic absorption of the flush liquid, including sorbitol, glycine or mannitol, can lead to complications, such as hyponatremia, volume overload and pulmonary or cerebral edema. Acute hyponatremia is defined as a reduction in the plasma sodium level in less than 48 h. Acute symptomatic hyponatremia should be corrected aggressively because it may cause irreversible neurological damage and death. Rapid correction of hyponatremia causes severe neurologic deficits, such as central pontine myelinolysis; thus, the optimal therapeutic approach has been debated. This article examined acute symptomatic hyponatremia in a patient undergoing transcervical myomectomy for a submucosal myoma. A thirty-seven-year-old patient was evaluated in obstetrics and gynecology clinic because of altered mental status and agitation. There was no history of chronic illness or drug use. It was discovered that during the operation, 12 L of the flush fluid, which contained 5 % mannitol, had been infused, but only 7 L of the flush fluid had been collected. On physical examination, the patient's general condition was moderate, her cooperation was limited, she was agitated, and her blood pressure was 120/70 mmHg. The sodium level was 99 mEq/L. Furosemid and 3 % NaCl solution were given. Her serum sodium returned to normal by increasing 39 mEq/L within 14 h. Her recovery was uneventful, and she was discharged 24 h after her serum sodium returned to normal. In conclusion, if there is a difference between the infused and collected volumes of the mannitol irrigant, severe hyponatremia may develop due to the flush fluid used during transcervical hysteroscopy and myomectomy. In these patients, acute symptomatic hyponatremia may be corrected as rapidly as the sodium level dropped.

Reproductive outcome after surgical treatment of endometriosis--retrospective analytical study.

OBJECTIVE: The aim of the study was to investigate the reproductive outcomes of patients after surgical treatment of endometriosis. MATERIAL AND METHODS: The study included 100 infertile women, aged 21 to 41 years, who underwent surgical treatment of endometriosis. From January 2007 to January 2012, excision of endometriosis was performed by operative laparoscopy or laparotomy Demographic, clinical, surgical and reproductive outcomes of 52 patients were retrospectively analyzed. RESULT: Twenty-three pregnancies (44%) were obtained in 52 patients, resulting in 16 term pregnancies, 4 spontaneous abortions under 16 weeks gestation, 2 spontaneous abortions at 20 gestational weeks and 1 ectopic pregnancy Twenty nine patients did not achieve pregnancy and 68.9% (20/29) of them were treated with IVF-ICSI. Spontaneous pregnancies were obtained within 7 months after the surgery whereas IVF-ICSI pregnancies were obtained within the period of 11 months. Seven patients were stage 1, 14 patients stage II, 19 patients stage III, and 12 patients stage IV according to the American Fertility Society (AFS) Classification of Endometriosis. The pregnancy rate was 57% in stages I-II, 47% in stage III, 16% in stage IV endometriosis; and the rate of term pregnancies was 83%, 66%, and 0%, respectively Seven pregnancies (7/14) were obtained in patients with bilateral endometriosis and 5 of them resulted in term pregnancy Sixteen pregnancies (16/38) were obtained in patients with unilateral endometriosis and 11 of them resulted in term pregnancy CONCLUSION: After surgical treatment of endometriosis, the pregnancy and live birth rates seem to be improved. Reproductive outcome is closely associated with the AFS score. Bilaterality of endometriosis does not affect pregnancy outcome.

High-output cardiac failure in a fetus with thanatophoric dysplasia associated with large placental chorioangioma: case report.

Placental chorioangioma is an angioma arising from chorionic tissue. Fetal thanatophoric dysplasia is a lethal skeletal dysplasia due to mutation of fibroblast growth factor receptor 3 gene. These two conditions are rare and their coexistence in a given fetus is even rarer. We present a case of a fetus with thanatophoric dysplasia having high-output cardiac failure due to a large placental chorioangioma.

Osteoprotective effect of hormone therapy on bone microarchitecture before impaired bone mineral density in ovariectomized rats.

OBJECTIVE: We aimed to determine the effect of hormone replacement therapy on bone microarchitecture in ovariectomized rats. MATERIAL AND METHODS: In the Animal Ethics Committee approved-study, the effect of treatment with 17 ß-estradiol 50 µg/kg and medroxyprogesterone 2.5 mg/kg on bone architecture and bone mineral density in rats versus ovariectomized control rats over the course of 20 days were evaluated. Femoral and lumbar bone mineral density levels and morphometric measurements were performed. RESULTS: There were no significant differences in the femoral and lumbar bone mineral density levels between the groups. In the intact control group, the trabecular structures were significantly superior to those in the other groups. Additionally, the osteoblast count was significantly higher while the osteoclast count was significantly lower than in all other groups. Two parameters reflecting trabecular bone microarchitecture, which include the trabecular count and the trabecular area, demonstrated significant improvement in the hormone replacement group when compared to the ovariectomized control group. In the hormone replacement groups, the osteoblast count was significantly higher while the osteoclast count was significantly lower than in the ovariectomized control group. CONCLUSION: We suggest that offering estrogen alone or in combination with progestogen can be a beneficial approach in preventing early postmenopausal bone loss regardless of bone mineral density.

Conservative management of placenta previa percreta by leaving placental tissue in situ with arterial ligation and adjuvant methotrexate therapy.

Placenta percreta is one of the life-threatening conditions in modern obstetrics. The rising caesarean section rate means rising placenta percreta rate. Treatment strategies range from a caesarean hysterectomy to leaving the placenta in situ with or without internal iliac artery ligation/uterine artery embolisation and/or methotrexate therapy. We describe a case of placenta previa percreta which we managed successfully with conservative modalities.

The immunohistochemical evaluation of VEGF in placenta biopsies of pregnancies complicated by preeclampsia.

OBJECTIVE: The study was designed to determine the protein levels of vascular endothelial growth factor (VEGF) in the placenta biopsies of patients with preeclampsia and compare with normal controls. DESIGN: Prospective cohort study. METHODS: The placental biopsies were obtained from ten patients with preeclampsia and ten patients of control group at the time of delivery. Avidin-biotin-peroxidase immunohistochemistry was then performed to identify levels of VEGF protein within the tissue and a semi-quantitative method was devised to score the amount of staining present in the sample. Two histopathologists who were blinded to the groups were asked to score each sample for the intensity of staining and the number of cells stained in a randomly selected per high-power fields of each sample. The resulting "H-score" was computed as a product of intensity and percent of cells stained. RESULTS: The VEGF expression was significantly higher in placenta biopsies of preeclamptic patients compared to that of controls (271.2 +/- 22.65 vs. 201.9 +/- 12.33, P = 0.000). CONCLUSION: Immunostaining of VEGF is significantly higher in placenta biopsies of patients with preeclampsia.

The effects of raloxifen on depression and cognition in ovariectomized rats.

This study investigates the effects of raloxifen on cognition and depression in an animal model.

Effect of BCG vaccine on peritoneal endometriotic implants in a rat model of endometriosis.

OBJECTIVE: To investigate the effect of Bacillus Calmette-Guerin (BCG) vaccine on peritoneal implantation of endometrial tissue in rats. METHODS: Forty sexually mature virgin Wistar albino rats weighing 190-200 g were randomly assigned (double blind) to two groups. The rats in the first group were vaccinated with 0.1 mL BCG and those in the second group were injected with 0.1 mL saline into the tail, intracutaneously. All the rats underwent median laparotomy after 4 weeks of vaccination or injection. The right uterine horn was excised, and the two samples of endometrial tissue dissected from myometrium were implanted on each side of peritoneum at the 2 cm lateral line of the median laparotomy incision. The implanted peritoneal segments were excised after 8 weeks of laparotomy. The tissue samples were accepted, histologically, as endometriosis when both glands and stroma of endometrial tissue were seen in sections. RESULTS: Thirty-six implants from the study group and 34 implants from the control group were obtained. Ten and 23 implants were accepted as endometriosis in the study and control group, respectively. The number of endometriotic foci were significantly lower in the study group than in the control group (P = 0.01). CONCLUSIONS: Stimulation of the cellular immune response with BCG vaccine could exert an inhibitory effect on ectopic endometriotic implants.

The value of the insulin-like growth factor binding protein-1 in the cervical-vaginal secretion detected by immunochromatographic dipstick test in the prediction of delivery in women with clinically unconfirmed preterm premature rupture of membranes.

OBJECTIVE: The aim of this study was to determine the value of detecting insulin-like growth factor binding protein-1 (IGFBP-1) in the cervical-vaginal secretion in the prediction of delivery in women with clinically uncorfirmed preterm premature rupture of membranes (PPROM). MATERIAL AND METHODS: A total of 87 women, gestational age between 20 and 36 weeks were enrolled into this prospective study. Based on the clinical diagnosis, patients were grouped as clinically evident PPROM (n = 25), clinically suspected PPROM (n = 42) and women with intact fetal membranes (n = 20). Detection of IGFBP-1 in the cervical-vaginal secretions was done using a one-step immunochromatographic dipstick test in all women. The outcome measures were gestational age at delivery, neonatal birth weight and duration of the interval between the test and delivery between women with positive and negative test results. RESULTS: The test was positive in all 25 women (100% sensitivity) with clinically evident PPROM and all delivered prematurely, and negative in 19 out of the 20 (95% specificity) women with intact fetal membranes. Among 36 women with clinically suspected PPROM, 13 (36%) tested positive and 23 (63%) tested negative for IGFBP-1. In this group, the mean gestational age and birth weight at the time of delivery were significantly lower in patients with positive test (31.38+/-2.6 weeks versus 38.61+/-0.99 weeks and 1761+/-527g versus 3500+/-355g, P < 0.05 for both). Eleven (85%) of the 13 women with positive test, delivered within 2 weeks after the performance of the test whereas all the women with negative test results delivered after 2 weeks (P = 0.001). The test had 100, 92, 84 and 100% sensitivity, specificity, positive predictive value and negative predictive value, respectively, for the outcome measure of test-delivery interval. CONCLUSION: The screening test for IGFBP-1 in the cervical-vaginal secretions is a useful adjunct in the prediction of delivery in women with clinically unconfirmed PPROM.

Value of cervical phosphorylated insulinlike growth factor binding protein-1 in the prediction of preterm labor.

OBJECTIVE: To determine the value of cervical phosphorylated insulinlike growth factor binding protein-1 (IGFBP-1) in the prediction of preterm labor. STUDY DESIGN: In this prospective study, 77 pregnant women, gestational age 24-36 weeks, were enrolled in the study. Twenty women with completely healthy pregnancies formed the control group. Fifty-seven women with signs and symptoms of preterm labor formed the study group. Phosphorylated IGFBP-1 in cervical secretions was assessed in all patients by using a qualitative, immunochromatographic, 1-step dipstick test. Cervical length was measured by transvaginal sonography. RESULTS: The IGFBP-1 test was negative in all patients in the control group (n = 20), and all of them delivered after 37 weeks, while the test was positive in 15 of 45 (33.3%) patients in the study group. The correlation between cervical length and gestational age at the time of delivery in patients with a positive phosphorylated IGFBP-1 test (n = 15) was significant (r = .553, P = .03). The sensitivity, specificity, positive predictive value and negative predictive value for the phosphorylated IGFBP-1 test were 78%, 87%, 73% and 90%, respectively. CONCLUSION: Use of a 1-step dipstick test for detecting phosphorylated IGFBP-1 in cervical secretions is of value in the prediction of preterm labor. The high negative predictive value of the test may be useful in avoiding unnecessary medical interventions.