The role of second trimester uterine artery Doppler in predicting obstetric and neonatal outcomes in abnormal first trimester maternal serum pregnancy-associated plasma protein-A and free ß-human chorionic gonadotropin values.

AIM: This study aims to determine whether second-trimester uterine artery (UtA) Doppler combined with first-trimester abnormal pregnancy-associated plasma protein-A (PAPP-A) and ß-human chorionic gonadotropin (ß-Hcg) levels predicts adverse obstetric and neonatal outcomes. MATERIALS AND METHODS: This study of 289 pregnant women included 196 with normal PAPP-A and free ß-HCG values (control group) and 93 with abnormal values (study group) in the first-trimester screening test. Second-trimester UtA Doppler sonography was done in these pregnancies. The perinatal prediction and screening potential of UtA Doppler pulsatility index (PI) parameters were examined in the study group. RESULTS: UtA PI >95 percentile increased birth before the 37th week by 4.46 times, birth before the 34th week by 7.44 times, preeclampsia risk by 3.25 times, fetal growth restriction (FGR) risk by 4.89 times, and neonatal intensive care unit (NICU) admission rates by 3.66 times in the study group (p < 0.05 for all). UtA PI >95 percentile had 49.2% sensitivity and 82.1% specificity for birth before 37 weeks. For birth before 34 weeks, sensitivity was 80.0% and specificity 65.0%. FGR has 70.5% sensitivity and 67.1% specificity. Screening for preeclampsia has 66.6% sensitivity and 61.9% specificity. CONCLUSION: Adding UtA Doppler in the second trimester to pregnancies with abnormal PAPP-A and/or free ß-Hcg values in the first trimester may be a useful screening method for adverse outcomes.

Plasma selenium levels in Turkish women with polycystic ovary syndrome.

OBJECTIVE(S): To evaluate selenium (Se) levels in serum and their relation with hyperandrogenism and insulin resistance (IR) in women with polycystic ovary syndrome (PCOS) and in control subjects. STUDY DESIGN: Women with any gynecological problem who presented to the Kahramanmaras Sutcuimam University Medical Faculty Gynecology and Obstetric Outpatient Clinic were invited to participate. Group 1 consisted of 36 cases with a diagnosis of PCOS according to the 2003 Rotterdam Consensus Criteria, and Group 2 (control group) consisted of 33 age- and BMI-matched healthy women. In all cases, serum total testosterone (tT), dihydroepiandrostenedione-sulfate (DHEAS), follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), insulin, glucose (mg/dL), total cholesterol (TC) (mg/dL), high density lipoprotein-cholesterol (HDL-C) (mg/dL), low density lipoprotein-cholesterol (LDL-C) (mg/dL), triglyceride (TG) (mg/dL) and Se levels were measured. RESULTS: The level of FSH was significantly lower, and the levels of LH, E2, tT, and DHEAS were significantly higher in group 1 than in group 2 (p<0.05). The hirsutism score was significantly higher among PCOS women compared to the control group (p<0.05). Although insulin levels and HOMA-IR were markedly increased in the PCOS group compared to the control group, the differences were not significant (p>0.05). The plasma Se level was significantly lower in PCOS women compared to the control group (p<0.05). When we combined the all women in two groups, regarding them as one group (combined group, n=69), a negative correlation between Se and LH and tT was present (p<0.05). CONCLUSION(S): Our results show decreased plasma concentrations of Se and a negative correlation between Se and LH, tT in women with PCOS. These results indicate that Se may play a role in the pathogenesis of PCOS related with hyperandrogenism.

Late recurrence of aggressive angiomyxoma of the vulva.

OBJECTIVE: Aggressive angiomyxoma (AA) is found mainly in the pelvis and perineum, with a female-to-male ratio of approximately 6:1. Although it is a slow growing tumor, AA has a marked tendency to local recurrence with a low metastasis capacity. The study aimed to describe a case of vulvar angiomyxoma recurred almost 20 years after its initial surgery. MATERIALS AND METHODS: We report the case of a 57-year-old gravida 5 para 4 woman with vulvar AA arising from the left labium majus, which recurred 20 years after initial surgery. There was a nontender, solid, mobile mass on the left vulva, which was 25 x 30 cm on physical examination. A pelvic computed tomographic scan showed a mass measuring 26 x 10 x 14 cm originating from left vulvar region, which has a fatty tissue density. RESULT: Under general anesthesia, total excision of the tumor was performed. Macroscopically, the tumor weighed 723 g and measured 33 x 20 x 10 cm. The histopathological examination of the specimen revealed a myxoid tumor with sparse infiltrates of spindle-shaped to stellate cells and vessels of varying sizes. The final histopathological diagnosis was AA. CONCLUSIONS: Aggressive angiomyxoma may form extremely large tumors, and recurrence is not rare even many years after primary surgery.

Selenium has a protective effect on ischemia/reperfusion injury in a rat ovary model: biochemical and histopathologic evaluation.

BACKGROUND/PURPOSE: The aim of the study was to evaluate the effects of selenium (Se) on ischemia/reperfusion (I/R) injury in rat ovaries. METHODS: Thirty-five female Sprague-Dawley rats were randomly divided into 5 groups (n = 7): sham (S), I/R1, I/R2, Se1, and Se2. In the I/R1 and Se1 groups, 4 hours of ischemia was followed by 6 hours of reperfusion, and in the I/R2 and Se2 groups, 4 hours of ischemia was followed by 12 hours of reperfusion. In the Se groups, 30 minutes before reperfusion, a single dose of 0.2 mg/kg Se was administered intraperitoneally. The ovarian tissue levels of malondialdehyde (MDA) and nitric oxide (NO), and the activities of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) were measured biochemically. Tissue damage to ovarian tissue was scored by histopathologic examination. RESULTS: The I/R groups had significantly higher MDA levels and lower CAT, SOD, and GPx activities than the sham group (P < .05). Although NO levels were significantly higher in the I/R1 group than in the sham group (P < .05), the NO levels in the I/R2 and sham groups were similar. Selenium pretreatment significantly lowered tissue MDA and NO levels and increased tissue SOD and GPx activities in the Se groups, compared with those in the I/R groups (P < .05). Catalase activities were significantly higher in the Se2 group than in the I/R2 group (P < .05). Catalase activities were higher in the Se1 group than in the I/R1 group, but the difference was not statistically significant. Treatment with Se significantly decreased the ovarian tissue damage scores in the Se2 group compared with those in the I/R2 group (P < .05). CONCLUSION: Selenium is effective in preventing tissue damage induced by I/R in rat ovaries.

Comparison of transforming growth factor ß1 concentrations in the ovaries of rats stimulated by human menopausal gonadotropin or recombinant follicle-stimulating hormone.

OBJECTIVE: To compare the effects of human menopausal gonadotropins (hMG) and recombinant follicle stimulating hormone (rFSH) on transforming growth factor (TGF) ß1 concentration in the rat ovary. STUDY DESIGN: Twenty-one fertile Wistar-Albino rats were divided into 3 groups of 7. Groups 1, 2 and 3 were injected with saline, hMG or rFSH, respectively, over 5 days, after which they underwent ovariectomy. Hematoxylin and eosin (H&E) staining was used for histological examination. TGF ß1 staining levels in ovarian stroma, vessel walls, granulosa cells of Graafian follicles and corpus luteum cells were investigated immunohistochemically. RESULTS: On histological examination, the number of smaller antral follicles was higher in the control group, while there were more and larger antral follicles in the hyperstimulated groups. There were statistically significant differences in staining in vessel walls and granulosa cells between the control and stimulated groups. Both stimulation protocols caused an increased TGF ß1 concentration in vessel walls, while there was weak staining in granulosa cells in the treatment groups compared to the control group (p<0.05). There were no significant differences in staining scores between the two treatment groups (p>0.05). CONCLUSIONS: The effects of two different gonadotropin preparations on TGF ß1 concentrations in different localizations in the rat ovaries are comparable. It may be postulated that the luteinizing hormone (LH) content of hMG contributes little or nothing to the TGF ß1 mediated angiogenesis.

Vulvar pyogenic granuloma in a postmenopausal woman: case report and review of the literature.

Introduction. Although pyogenic granulomas (PG) are common and benign vascular proliferations of the skin and mucous membranes, they are relatively rare on the vulva. Case Presentation. A 57-year-old G7P7 postmenopausal woman presented with a 3-year history of a foul smell and bleeding lesions in the genital region. A gynecologic examination revealed multiple large papillomatous, pedunculated, and lobulated lesions that were cherry-red and infective in appearance. There was a 2-cm lesion at the upper intersection of the labia majora, a 2-cm lesion on the right labium majus, and a 4-cm lesion on the clitoris. The patient complained of itching, and the lesions were asymptomatic, except for occasional bleeding. All lesions were excised and sent for histopathological examination, which revealed an ulcerated polypoidal structure with extensive proliferation of vascular channels lined by a single layer of endothelium. The histopathological features were consistent with PG. Conclusion. The present case is the first case of multiple pyogenic granulomas on the vulva in a postmenopausal woman.

Modified Ferriman-Gallwey hirsutism score and androgen levels in Turkish women.

OBJECTIVE(S): To evaluate a modified Ferriman-Gallwey (mFG) scoring system and serum total testosterone (tT) and dehydroepiandrosterone sulfate (DHEAS) levels, in women with polycystic ovary syndrome (PCOS) and in control subjects. STUDY DESIGN: Women with any gynecological problem who presented to the Kahramanmaras Sutcuimam University Medical Faculty Gynecology and Obstetric Outpatient Clinic in the Mediterranean region of Turkey were assessed prospectively. Oligo-anovulation, clinical and biochemical hyperandrogenism, and PCO appearance on ultrasound that met the 2003 Rotterdam Consensus Criteria were used for PCOS diagnosis. Group 1 consisted of 43 cases with a diagnosis of PCOS and group 2 (control group) consisted of 75 age and BMI matched control subjects without PCOS. RESULTS: In groups 1 and 2, clinical hyperandrogenism (hirsutism) appearance ratio was 86.0% (37/43) and 18.0% (15/75) (p < 0.001); while biochemical hyperandrogenism (high serum tT or DHEAS level) was 65.1% (28/43) and 36% (27/75) (p < 0.05), respectively. In groups 1 and 2, mean serum tT levels were 115.2 and 73.4 ng/dL (p < 0.001), mean serum DHEAS levels were 256.1 and 177.7 ng/dL (p < 0.001), and mean hirsutism scores were 11.2 and 5.5 (p < 0.001), respectively. Serum mean tT, DHEAS and hirsutism scores for group 1 were significantly higher than those of group 2 (<0.001). No correlation was observed between BMI and the hirsutism scores or the biochemical hyperandrogenism in both groups. CONCLUSION(S): In our study, mean serum androgen levels and hirsutism ratio in the PCOS group were higher than the control group. These values were also substantially higher than those previously published in the literature.

The relationship between serum testosterone levels and bladder storage symptoms in a female population with polycystic ovary syndrome.

OBJECTIVES: To examine the relationship between bladder symptoms and serum testosterone levels in women with polycystic ovary syndrome (PCOS). MATERIALS AND METHODS: A total of 140 patients diagnosed with PCOS according to ESHRE/ASRM criteria in two clinics were evaluated for the effects of testosterone on bladder symptoms. The effect of testosterone on bladder symptoms was quantified by self-administered pelvic pain and urgency/frequency questionnaire (PUFq) and an extra special question performed for urge incontinence. Ultrasonographic bladder capacity and postvoid residual volume were also recorded in all patients. Correlation between serum testosterone level and total, symptom and bother scores of PUFq, score of each question of PUFq separately, and ultrasonographic findings were analyzed. RESULTS: The median (range) age, testosterone, DHEAS, estradiol, glucose, urine pH, urine density, ultrasonographic bladder capacity, and PUFq score were 25 years (17-40), 53 ng/dl (25-229), 258 µg/dl (92-645), 74 pg/ml (20-184), 81 mg/dl (62-128), 5.5 (4.8-7.0), 1.015 (1.001-1.028), 400 ml (100-650), and 2.5 (0-23), respectively. Significant positive correlation was found between serum testosterone level and total, symptom and bother scores of PUFq, symptom of dyspareunia, urgency, nocturia, and bladder/pelvic pain. There was no correlation between serum testosterone level and ultrasonographic findings such as bladder capacity, postvoid residual volume and symptom of frequency. CONCLUSIONS: This study indicates that women who have higher serum testosterone level are more likely to report bladder symptoms.

Plasma lipocalin-2 levels in pregnant women with pre-eclampsia, and their relation with severity of disease.

OBJECTIVE: To compare lipocalin-2 (LCN2) levels in pre-eclamptic women with those in healthy pregnant women, and to determine whether there is a correlation between LCN2 levels and the severity of the disease. METHODS: The study included 66 pregnant women: 22 healthy pregnant women (Group 1), 23 women with mild pre-eclampsia (Group 2), and 21 women with severe pre-eclampsia (Group 3). Pre-eclamptic women and normal controls were carefully matched for maternal age, gestational age, and body mass index (BMI). The maternal levels of plasma LCN2 were determined by enzyme-linked immunosorbent assay. RESULTS: Plasma LCN2 levels in the pre-eclamptic group were significantly lower than those in the healthy control group (p < 0.05). Although plasma LCN2 level was lower in the severe compared to the mild pre-eclamptic group, the difference was not statistically significant (p > 0.05). There was no significant correlation between LCN2 levels and the homeostasis model assessment of insulin resistance (HOMA-IR), BMI, triglyceride, gestational week at delivery, birth weight, and systolic and diastolic blood pressure in pre-eclamptic and healthy pregnant women (p > 0.05). CONCLUSIONS: Our results show that there are decreased concentrations of plasma LCN2 in pre-eclamptic subjects and this may indicate that LCN2 plays a role in the pathogenesis of pre-eclampsia. However, further experiments are needed to clarify this role.

Unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate.

BACKGROUND: Spontaneous tubal twin pregnancy is a rare condition with an incidence of 1 in every 125,000 pregnancies. We present the case of a unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate. CASE: A 26-year-old nulliparous woman was admitted to our clinic with a complaint of vaginal bleeding and leftside pelvic pain. Her serum ß-human chorionic gonadotropin (ß-hCG) level was 18,780 mIU/mL and ultrasound revealed tubal twin pregnancy of 7 weeks' gestation. Because her vital signs were stable and no sign of tubal rupture was present, we performed single-dose (100 mg) methotrexate intramuscularly. In the follow-up, serum ß-hCG levels were found to be 7,600 mIU/ml on day 7, 948 mIU/ml on day 20, 126 mIU/ml on day 26 and <10 mIU/ml on day 42. CONCLUSION: Methotrexate theraphy may be preferred in tubal twin ectopic pregnancies when the vital signs of the patient are stable and the fetal cardiac activities are negative.

Protective effect of tadalafil on ischemia/reperfusion injury of rat ovary.

BACKGROUND/PURPOSE: The aim of the study was to evaluate the effects of tadalafil (TDF) on ischemia/reperfusion (I/R) injury in rat ovaries. METHODS: Thirty-five female Sprague-Dawley rats were randomly divided into 5 groups (n = 7): sham (S), I/R1, I/R2, TDF1, and TDF2. In the I/R1 and TDF1 groups, 3-hour ischemia was followed by 12-hour reperfusion; and in the I/R2 and TDF2 groups, 3-hour ischemia was followed by 24-hour reperfusion. In the TDF groups, 30 minutes before reperfusion, a single dose of 5 mg/kg TDF was administered intraperitoneally. The ovarian tissue levels of malondialdehyde and nitric oxide (NO), and the activities of superoxide dismutase and catalase were measured biochemically. Tissue damage to ovarian tissue was scored by histopathologic examination. RESULTS: The tissue malondialdehyde levels were significantly higher and the catalase and superoxide dismutase activities were significantly lower in the I/R groups compared with the S and TDF groups (P < .05). The NO levels were significantly higher in the TDF1 group than the S and I/R1 groups (P < .05). Although the NO levels were increased in the TDF2 group compared with the I/R2 group, the difference was not significant. Ovarian tissue damage scores of the I/R groups were significantly higher than those of the S group (P < .05). Treatment with TDF significantly decreased the ovarian tissue damage scores in the TDF groups compared with the I/R groups (P < .05). CONCLUSIONS: Tadalafil is effective in preventing tissue damage induced by I/R in rat ovaries.

Association of maternal serum CRP, IL-6, TNF-alpha, homocysteine, folic acid and vitamin B12 levels with the severity of preeclampsia and fetal birth weight.

OBJECTIVE: To assess the levels and clinical significance of high sensitive(hs)-CRP (C-reactive protein), IL-6(interleukin-6), TNF-alpha(tumor necrosis factor-alpha), homocysteine, folic acid and vitamin B12 in normotensive healthy pregnant women, mild and severe preeclamptic patients, and to evaluate the correlations between these markers and the severity of preeclampsia and fetal birth weight. STUDY DESIGN: Using a cross-sectional study design, hs-CRP, IL-6, TNF-alpha, homocysteine and vitamin B12 were measured in the third trimester of pregnancy from normotensive healthy women with uncomplicated pregnancies (n = 62), mild (n = 61) and severe (n = 60) preeclamptic patients. RESULTS: There were statistically significant differences between three groups for hs-CRP (p = 0.012), TNF- alpha (p = 0.046), IL-6 (p = 0.015), homocysteine (p < 0.001) and fetal birth weight (p < 0.001). Fetal birth weights in mild (2477 +/- 746) and severe (2435 +/- 768) preeclamptic patients were significantly lower than controls (3485 +/- 365) (p < 0.001). No significant difference was found between the three groups for folic acid (p = 0.066) and vitamin B12 (p = 0.286). Bonferroni adjusted multiple comparison test showed that the statistical differences with respect to TNF-alpha, IL-6 and homocysteine were mainly created by control and severe preeclampsia groups. Hs-CRP levels still remained higher in severe preeclampsia patients than mild preeclampsia and normotensive patients except for overweight patients in the previous two groups after Bonferroni post hoc adjustment test. CONCLUSION: Elevated maternal serum levels of hs-CRP, TNF- alpha, IL-6 and homocysteine in preeclamptic women correlate with fetal birth weight in the early third trimester.

Uterus didelphys with an obstructed unilateral vagina by a transverse vaginal septum associated with ipsilateral renal agenesis, duplication of inferior vena cava, high-riding aortic bifurcation, and intestinal malrotation: a case report.

OBJECTIVE: To present a case of müllerian defects associated with other anomalies, including ipsilateral renal agenesia, duplication of inferior vena cava, high-riding aortic bifurcation, and intestinal malrotation. DESIGN: Case study. SETTING: Academic medical center. PATIENT(S): A 16-year-old woman with müllerian defects associated with vascular and intestinal anomalies. INTERVENTION(S): Excision of vaginal septum. MAIN OUTCOME MEASURE(S): Improvement of symptoms caused by obstructed müllerian defect. RESULT(S): After an incision on the vaginal septum, a large amount of chocolate-colored fluid was drained, and the dimensions of the right uterus were diminished. Then the vaginal septum was excised completely; we saw a second distinct cervical portion. CONCLUSION(S): Uterus didelphys with obstructed hemivagina is almost always associated with renal agenesis ipsilateral to the obstruction. Inferior vena cava duplication associated with müllerian anomalies is an extremely rare condition. In addition, the presented case also had a high-riding aortic bifurcation and intestinal malrotation. To the best of our knowledge, this is the first case to include all of these anomalies.

Can screening Chlamydia trachomatis by serological tests predict tubal damage in infertile patients?

Effectiveness of screening Chlamydia trachomatis (CT) antibody to predict tubal damage was assessed in this prospective study which was performed in a teaching hospital between September 2003 and September 2004. The study group consisted of 152 patients who underwent laparoscopy for infertility and the control group consisted of 80 fertile women who gave birth in the same hospital. CT antibody levels were measured by IFA (Indirect Fluorescence Assay for CT). Adhesions were defined by Gomel's classification system. Rate of seropositivity of CT was 34.6% in the study group and 22.5% in the control group (p>0.05). In the study group, the sensitivity, specifity, positive predictive and negative predictive values of CT positivity for tubal damage were 40%, 69.5%, 50% and 60.2% respectively. In the infertile group, the rate of tubal adhesion in the CT positive group was 50% and in the CT negative group it was 39.7% (p>0.05). However, there was a positive correlation between the severity of tubo-peritoneal adhesions and seropositivity for CT. In this study, we found out that tubo-peritoneal adhesions could not be predicted by the presence of CT inserum. There was a positive correlation between high CT seropositivity and high degree of adhesions.

The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report.

BACKGROUND: Mc Indoe vaginoplasty is one of the mostly performed surgical interventions in Mullerian agenesis. CASE PRESENTATIONS: We present our experience on the use of a new designed vaginal stent that was coated with silicone in two mullerian agenesis cases who had Mc Indoe vaginoplasty. Both full thickness and splitt thickness skin graft were used with the stent. No graft loss or hyperthrophic scarring which may be seen at the apex of neovagina after Mc Indoe vaginoplasty was observed during the follow-up period and adequate neovaginal depth were obtained in both of the patients. CONCLUSION: We think that the incorporation of silicone to a vaginal stent for postoperative wound care improves skin graft take and decreases a possible constriction band formation in neovagina.

Combining mid-trimester maternal plasma homocysteine with uterine artery doppler velocimetry: is it useful?

OBJECTIVE: To investigate the possible association between mid-trimester maternal plasma homocysteine concentration, uterine artery Doppler measurements in a two-stage screening strategy, and outcome of pregnancy. MATERIALS AND METHODS: This prospective observational study was conducted on healthy women undergoing screening for pre-eclampsia by uterine artery Doppler velocimetry at 20-22 and 24-26 weeks of gestation. Abnormal uterine artery blood flow was defined as an average resistance index (RI) > 0.58 and/or bilateral early diastolic notch. Homocysteine measurement was performed by two competitive immunoassay methods involving two steps at 20-22 and 24-26 weeks' gestation. RESULTS: Sixty women enrolled. Abnormal Doppler findings were found in 18 of 60 (30%) women at 20-22 weeks of gestation. This proportion was reduced to 10% (6/60) at 24-26 weeks of gestation, and two of these six women developed pre-eclampsia later in pregnancy. There was no significant difference in the maternal plasma homocysteine levels in women with abnormal Doppler findings when compared with controls at first and second visits (p > 0.05). CONCLUSION: Mid-trimester maternal homocysteine concentration is not elevated in women with abnormal uterine artery Doppler findings in a two-stage screening method.

Use of an aromatase inhibitor in patients with polycystic ovary syndrome: a prospective randomized trial.

OBJECTIVE: To compare the use of an aromatase inhibitor (letrozole) with the use of clomiphene citrate (CC). DESIGN: Prospective randomized study. SETTING: An infertility clinic in a university hospital. PATIENT(S): Seventy-four consecutive infertile patients with polycystic ovary syndrome were recruited. Thirty-eight patients were randomized to the letrozole group (99 cycles), and the remaining patients were recruited to the CC group (95 cycles). INTERVENTION(S): The aromatase inhibitor letrozole (2.5 mg/d) and CC (100 mg/d) were administered orally on days 3-7 of menses. MAIN OUTCOME MEASURE(S): Number of follicles, endometrial thickness, E(2) levels on hCG day, and pregnancy rates among both groups. RESULT(S): Ovulation occurred in 65.7% (65/99) of letrozole cycles and in 74.7% (71/95) of CC cycles. The median (minimum-maximum) number of follicles sized >15 mm in diameter on the day of hCG administration were 1 (0-4) and 1 (0-5) in the letrozole and CC groups, respectively. On the day of hCG administration, median serum E(2) concentrations in the letrozole and CC groups were statistically significantly different: 189 pg/mL (18-1,581 pg/mL) and 386 pg/mL (27-6,190 pg/mL), respectively. The median serum E(2) concentrations per follicle sized >15 mm in diameter on the day of hCG also statistically significantly differed between the letrozole and CC groups: 160 pg/mL (18-808 pg/mL) and 281 pg/mL (27-2,615 pg/mL), respectively. The median endometrial thickness on the day of hCG did not significantly differ between the CC and letrozole groups; it was 8 mm. Pregnancy was achieved in nine cycles (9.1%) of the letrozole group and in seven cycles (7.4%) of the CC group, which also was not a statistically significant difference. CONCLUSION(S): The aromatase inhibitor letrozole may be an acceptable alternative to CC as an ovulation-induction drug in patients with PCOS.