A novel predictive model of lymphovascular space invasion in early-stage endometrial cancer.

Objective: To predict lymphovascular space invasion (LVSI) positivity in early-stage (stage 1-2) endometrial cancer (EC) using a predictive model with prognostic factors of EC. Materials and Methods: We included 461 patients who underwent total hysterectomy and bilateral salpingo-oophorectomy with pelvic-paraaortic lymphadenectomy as the primary treatment for presumed early-stage EC at our clinic between 2010 and 2020. Moreover, all surgical specimens were examined histopathologically for the positivity or negativity of LVSI, and the patients were divided into two groups based on these pathologic outcomes. Age, menopausal status, histological type (type 1-2), histological grade (grades 1-2-3), depth of myometrial invasion, and peritoneal cytology results were recorded and analyzed as clinicopathological and demographic characteristics of the patients. The Loess algorithm determined the relationship between the observed and predicted outcomes. The distinction between the algorithms was evaluated by calculating the C-index. Results: LVSI positivity was significantly associated with advanced age, menopause, type 2 EC, advanced histological grade, malignant peritoneal cytology, cervical involvement, and a tumor exceeding 50% of the myometrial depth (p<0.001, respectively). Remarkably, LVSI was most strongly associated with three explanatory variables: 1- More than 50% myometrial invasion [odds ratio (OR): 3.78; 95% confidence interval (CI): 1.80-7.60], 2- Advanced histological grade [OR=1.98 (1.20-3.20) 95% CI], 3- Malignant peritoneal cytology [OR= 3.06 (1.40-6.30) 95% CI]. The penalized maximum likelihood estimation model correctly classified 87% of the included patients (C-index: 0.876). Conclusion: Our predictive model may help predict LVSI based on different prognostic factors. The prognostic factors included in the nomogram were significantly associated with LVSI, particularly myometrial invasion depth of more than 50%, advanced histological grade, and malignant peritoneal cytology.

The potential role of preoperative cystoscopy for determining the depth of invasion in the placenta accreta spectrum.

OBJECTIVES: This study aims to determine the role of preoperative cystoscopy in specifying the degree of placental invasion to the bladder in the placenta accreta spectrum (PAS), especially in percreta. MATERIAL AND METHODS: This prospective observational cohort study included 78 PAS patients. All included patients underwent the preoperative cystoscopy before the cesarean hysterectomy operation. The preoperative cystoscopy procedure identified markers of PAS as neovascularization, arterial pulsatility in neovascularized zones, and posterior bladder wall bulging. Then the patients were divided into subgroups according to the histopathological results of their cesarean hysterectomy specimens. Finally, the histopathological subgroups of PAS were estimated using preoperative cystoscopy signs in the designed logistic regression analysis model. RESULTS: The preoperative cystoscopic signs such as neovascularization, the posterior bladder wall bulging, and the arterial pulsatility in neovascularized zones were approximately associated with a 17-fold [OR = 16.9 (95% CI, 5.7-49.8)], 26-fold [OR = 26.1 (95% CI, 8.17-83.8)], and 9-fold [OR = 8.94 (95% CI, 2.94-27.1)] increase in the likelihood of placenta percreta, respectively. CONCLUSIONS: Preoperative cystoscopy may significantly contributions to other standard imaging modalities to identify the degree of placental invasion, especially placenta percreta. Experienced obstetricians trained in hysteroscopic visualization may safely perform this preoperative cystoscopy procedure under the guidance of a specialist urologist. Accordingly, it may be possible to estimate the degree of invasion and the course of surgery in patients with PAS using the preoperative cystoscopy procedure.

Predictor Factors in the Success of Slow-Release Dinoprostone Used for Cervical Ripening in Pregnancies with Premature Rupture of Membranes.

OBJECTIVE: The study aimed to evaluate the factors affecting successful vaginal delivery in induction with slow-release dinoprostone at term pregnancy with premature rupture of membranes. MATERIALS AND METHODS: Pregnancies between 370/7 and 416/7 gestation weeks with premature rupture of membranes in which slow-release dinoprostone was used for cervical ripening were sought for inclusion in the study. Pregnancies with previous uterine surgery, multiple fetal gestations, chorioamnionitis, non-cephalic presentation, fetal distress at the time of admission, HIV positivity, and estimated fetal weight >4500 on ultrasonographic evaluation were excluded. The primary outcome of measures were factors affecting the success of vaginal delivery including maternal age, gestational weeks at delivery, initial Bishop score, parity, induction time, and induction-delivery time interval. To reduce the risk of overfitting in the study, penalized maximum likelihood estimation was performed instead of traditional logistic regression in the statistical analysis. RESULTS: A total of 1266 participants who met the study criteria were included in the study. Among the parameters evaluated for the prediction of successful vaginal delivery in cases with premature rupture of membranes, maternal age (P < .001), Bishop score (P < .001), parity (P=.01), induction time (P < .001), and induction-delivery time interval (P < .001) had an impact on success. The mean gestational week of the participants who had cesarean deliveries was lower than in those who had vaginal deliveries (P=.03); however, this was not a predictor factor of penalized maximum likelihood estimation (P=.70). CONCLUSION: Basic parameters such as maternal age, induction time, parity, and Bishop score can be used to predict successful vaginal birth following dinoprostone slow-release vaginal insert administration.

Is there a role of prophylactic bilateral internal iliac artery ligation on reducing the bleeding during cesarean hysterectomy in patients with placenta percreta? A retrospective cohort study.

OBJECTIVES: Our study aims to evaluate the effect of bilateral prophylactic internal iliac artery ligation (IIAL) on bleeding in patients with placenta percreta who undergo cesarean hysterectomy (CH) with the use of blunt dissection technique. MATERIAL AND METHODS: This retrospective cohort study included 96 patients with placenta percreta who underwent planned CH with using the blunt dissection technique to allow better vesico-uterine dissection at the gynecology and obstetrics unit of a university hospital between the years 2017-2019. We carried out bilateral IIAL before CH in the study group (group 1) while we performed only CH in the control group (group 2). RESULTS: Group 1 and Group 2 consisted of 50 and 46 patients; respectively. There was no statistical difference between the two groups as regards to the mean estimated blood loss, the mean transfused blood products, the mean operation time, and the number of complications. In total, 24 patients (25%) had complications with the finding that the most common one was bladder injury (16/96, 16,66%). CONCLUSIONS: Routine bilateral prophylactic IIAL before CH in placenta percreta cases does not have a beneficial effect on decreasing the amount of bleeding and the amount blood transfusion.

Explanatory variables and nomogram of a clinical prediction model to estimate the risk of caesarean section after term induction.

The aims of this study were to identify the explanatory variables associated with failure of induction of labour (IOL) and to designate nomograms that predict probability. This retrospective study included 1328 singleton term pregnant women (37-42 weeks). The penalised maximum likelihood estimation (PMLE) method was used instead of traditional logistic regression. Of the 25,678 deliveries that occurred during the study period, 1328 (5.1%) women underwent term delivery. Of those, 1125 (84.7%) had successful vaginal deliveries and 203 (15.3%) had failed vaginal deliveries following use of a dinoprostone slow-release vaginal insert. Explanatory variables were discovered that were associated with delivery failure in term pregnancy undergoing induction of labour with an unfavourable cervix, and a nomogram that predicted probability was developed.IMPACT STATEMENTWhat is already known on this subject? The caesarean rate has continued to climb worldwide over the past decade. Most caesarean sections are performed because of suspected foetal distress or failure to progress. In absolute numbers, most caesarean deliveries are performed in women with a term pregnancy with a foetus in cephalic presentation. Despite these numbers, predicting the mode of delivery by which these women will deliver remains a challenge.What do the results of this study add? Five explanatory variables were strongly associated with failure of dinoprostone delivery of term pregnancies: nulliparity, induction time, premature rupture of membranes, Bishop score and foetal genderWhat are the implications of these findings for clinical practice and further research? The developed nomograms enable fast and easy implementation in clinical practice. After external validation and proof of generalisability, the present model could be used in obstetric clinical management.

Predictor variables in the success of slow-release dinoprostone used for cervical ripening in intrauterine growth restriction pregnancies.

OBJECTIVE: This study aims to evaluate the consequences of a trigger by vaginal Dinoprotone on outcome of pregnancies with Intrauterine growth restriction (IUGR). MATERIALS AND METHODS: This retrospective study included 161 induced IUGR fetuses (35-39 weeks). Consecutive patients who were evaluated formed the basis of the clinical outcomes. The penalized maximum likelihood estimation (PMLE) method was used instead of traditional logistic regression in order to reduce the risk of overfitting. RESULTS: Of the 25,678 deliveries that occurred during the study period, 161 (0.6%) women underwent IUGR delivery; of these, 117 (73%) succeeded and 44 (27%) failed to achieve cervical ripening using the dinoprostone slow-release vaginal insert. Two predictors were associated with dinoprostone vaginal delivery success: Parity (OR:1.4([0.89-2.3]), and Bishop score (OR:1.54[1.23-1.94]). The PMLE model correctly classified 78% participants (c-index: 0.78). CONCLUSION: Basic parameters such as parity and Bishop score can be used to predict successful vaginal birth following dinoprostone slow-release vaginal insert administration.

A comparison between a combination of letrozole and clomiphene citrate versus gonadotropins for ovulation induction in infertile patients with clomiphene citrateresistant polycystic ovary syndrome - a retrospective study.

OBJECTIVES: The aim of this study was to compare a combination treatment with CC plus letrozole versus gonadotropins in CC-resistant polycystic ovary syndrome (PCOS) patients with regard to ovulation and clinical pregnancy rate. MATERIAL AND METHODS: One hundred sixteen CC-resistant infertile PCOS patients were evaluated retrospectively. The patients were divided into two groups. Group 1 (n = 73) received CC plus letrozole, and Group 2 (n = 43) received gonadotropins. RESULTS: The ovulation rate in Group 1 was 65/73 (89%), the pregnancy rate was 13/73 (18%), the twin foetuses rate was 1/73 (1.3%) and the miscarriage rate was 2/73 (2.7%). In Group 2, the ovulation rate was 41/43 (95%), and the pregnancy rate was 8/43 (19%) the rate of the twin foetuses was 1/43 (2.3%) and the miscarriage rate was 1/43 (2.3%). There was no statistically significant difference in the ovulation (p = 0.25), pregnancy (p = 0.91), twin foetuses (p = 0.89) and miscarriage p = 0.89) rates between two groups. CONCLUSIONS: This new drug combination suggests that it may be a lower cost, lower risk alternative treatment that increases the rate of ovulation. Larger randomized clinical trials are needed to provide information on live birth rates of this combination.

The thiol/disulfide balance in ketone positive and ketone negative pregnant women with nausea and vomiting - a prospective study in a tertiary center.

OBJECTIVES: We aimed to investigate the thiol/disulfide balance in ketone positive (hyperemesis gravidarum) and ketone negative pregnant women with nausea and vomiting. MATERIAL AND METHODS: A total of 60 patients under the 14th week of pregnancy were included in this study, and they were divided into two groups. Group 1 included 30 pregnant women with ketone positive, group 2 included 30 ketone negative pregnant women with nausea, and vomiting. RESULTS: The native thiol, disulfide, and total thiol concentrations were measured using an automated method and compared among the two groups. There were also three indexes that are derived from disulfide, native and total thiol (Index 1 = 100 × disulfide/native thiol); (Index 2 = 100 × disulfide/total thiol); (Index 3 = 100 × native thiol/total thiol). When compared with Group 1 and Group 2, total thiol was high, native thiol was low but not statistically significant. Disulphide (p = 0.046), index 1 (p = 0.036) and index 3 (p = 0.034) were statistically significant. CONCLUSIONS: Patients with ketone positive are shifting to OS direction due to lack of nutrients and electrolytes. This study emphasizes the therapeutic potential of antioxidant supplementation, which is becoming an increasingly used approach in treating the symptoms of women with ketone positive.

Risk factors for relaparotomy after cesarean section due to hemorrhage: a tertiary center experience.

Aim: This study aimed to examine the risk factors for relaparotomy after cesarean section (RLACS) due to bleeding.Material and methods: In this retrospective descriptive case-control study, women who underwent RLACS only for bleeding between 2008 and 2019 at a single tertiary center were examined (the center oversees approximately 25,000 deliveries per year). Maternal characteristics, postoperative findings, and surgical features were compared with a control group that included non-complicated cesarean sections (CS). Multivariable logistic regression analysis was used to identify the risk factors for relaparotomy.Results: Relaparotomy complicated 0.07% (n = 40) of CS during the study period (n = 58,095). When compared with the control group, age, parity, estimated blood loss (EBL), postoperative pulse, blood replacement, and length of hospital stay were statistically higher in patients undergoing relaparotomy, whereas their postoperative systolic and diastolic blood pressure were found to be low. A history of pelvic surgery, the need for intensive care, and complications were more frequent in patients undergoing relaparotomy. When CSs were grouped according to 8-h periods of the day, it emerged that relaparotomies were mostly performed on the patients who underwent CS after working hours. Time interval during the day of the CS [OR: 2.59 (1.10-6.12)] and high postoperative pulse rate [OR: 1.58 (1.28-1.96)] were found to be independent risk indicators for RLACS (AUC: 0.97).Conclusions: Monitoring vital signs in the postoperative period and increasing the number of physicians and nurses during off-hours in hospitals working with on-call duty procedures as determined by the Ministry of Health will reduce the incidence rate of relaparotomy, maternal morbidity, and mortality due to hemorrhage.

Evaluation of catalase, myeloperoxidase and ferroxidase values in pregnant women with hyperemesis gravidarum.

OBJECTIVES: To investigate maternal serum catalase, myeloperoxidase and ferroxidase levels in pregnant women withHyperemesis Gravidarum and to compare the results with healthy pregnancies. MATERIAL AND METHODS: In this study, 60 female patients admitted to the Health Sciences University, Gazi Yasargil Trainingand Research Hospital, Gynecology and Obstetrics Department were evaluated. The patients were divided into two groups:Group 1 included 30 pregnant women with hyperemesis gravidarum; Group 2 included 30 healthy pregnant women.Pregnancies over 14 weeks were excluded from the study. RESULTS: The laboratory and laboratory characteristics of both groups are shown in Table 1. No significant differences werefound between the groups in terms of the maternal age, gestational age, gravidity, parity, fasting glucose level, and BMI.The maternal blood CAT levels were significantly higher in the HG group (219.6 ± 111.3 kU/L) when compared to the controlgroup (71.5 ± 52.5 kU/L) (p < 0.001). The maternal blood MPO levels were lower in the control group (121.5 ± 36.3 U/L)than in the study group (90.9 ± 56.4 U/L) (p = 0.016). However, the ferroxidase levels were similar between the twogroups. The independent variables BMI, age, parity, gravidity and gestational week effects were adjusted according to thelogistic regression method with groups. Significant differences were observed between the two groups in the levels ofCAT (0.001), MPO (0.005) values. CONCLUSIONS: This study suggests that antioxidants in response to oxidative stress gave different reactions with differentmechanisms; Also, we believe that insufficient food intake suppresses the immune system and this has an important roleon antioxidants.

Maternal abdominal subcutaneous fat thickness as a simple predictor for gestational diabetes mellitus.

Background To date, only a limited number of studies have evaluated the importance of abdominal subcutaneous fat thickness (ASFT) on gestational diabetes mellitus (GDM) screening. The aim of this study was to investigate the effectiveness of ASFT measurement during routine obstetric ultrasound performed between 24 and 28 weeks of gestation in predicting cases with GDM. Methods This prospective comparative study was conducted on 50 cases with GDM and 50 cases without GDM in the GDM screening program at 24-28 gestational weeks between January 2018 and May 2018. The most accurate ASFT cut-off point values were determined for the prediction of cases with GDM by performing receiver operator characteristic (ROC) curve analysis. Results The ASFT was higher in those with GDM compared to those without GDM (P < 0.05). For an ASFT cut-off point value of 18.1 mm for the prediction of cases with GDM, the sensitivity, specificity, negative and positive predictive values were 72.0%, 60.0%, 64.2% and 68.1%, respectively. The risk of GDM increased 3.86-fold in those with ASFT level >18.1 mm (P = 0.001). Conclusion The ASFT value measured by routine obstetric ultrasound performed at 24-28 weeks of gestation was found to be significantly higher in patients with GDM in comparison to those without GDM. However, further multi-centered and comprehensive prospective studies are required to better demonstrate this relationship.

The prevalence of uterine anomalies in infertile patients with polycystic ovary syndrome: A retrospective study in a tertiary center in Southeastern Turkey.

OBJECTIVE: To evaluate the prevalence of uterine anomalies in infertile patients with polycystic ovary syndrome (PCOS) admitted to our tertiary hospital in Southeastern Turkey. MATERIALS AND METHODS: The files of 3033 patients with infertility who presented to the infertility polyclinics were retrospectively analyzed, and uterine anomalies were detected in 131 patients. Seven hundred ten of these patients were evaluated as having PCOS, 55 of whom had uterine anomalies. Patients with PCOS were also divided into two subgroups as those with primary and secondary infertility. RESULTS: Of the 3033 patients with infertility who were evaluated, 57 (8%) of 710 infertile patients with PCOS, and 74 (3%) of 2323 non-PCOS patients with infertility had uterine anomalies. A statistically significant difference was found between the two groups (p<0.001), and no significant difference was found between the primary and secondary infertile PCOS subgroups (p=0.3). Septate uteri and arcuate uteri had a high prevalence in the PCOS group, and no t-shaped or hypoplastic uteruses were observed in this group. CONCLUSION: To or knowledge, this is the first study in our region to examine the relation between PCOS and Müllerian anomalies. We demonstrated uterine anomalies and their prevalence in patients with infertility. A more careful examination is required in order to determine the incidence of uterine anomalies in patients with PCOS.

The potential of serum fetal DNA for early diagnosis of gestational trophoblastic disease.

OBJECTIVE: To study cell-free DNA (cfDNA) levels in patients with gestational trophoblastic disease (GTD) in order to test the hypothesis that cfDNA circulating in maternal plasma could provide early detection of GTD. MATERIALS AND METHODS: This study included 32 patients with GTD (complete mole and partial mole) and 30 non-GTD patients in the first trimester of pregnancy with no other medical problems. cfDNA levels in maternal serum were measured using polymerase chain reaction analysis on Y-chromosome-specific sequences. RESULTS: cfDNA was found as 327±367 pg on average in the control group and 600±535 pg in the GTD group. Within the GTD group, the partial mole group had an cfDNA average of 636±549 pg, and the complete mole group had an cfDNA average of 563±536 pg. Although there was a statistically significant difference between the GTD group and the control group in terms of cfDNA (p=0.02), there was no statistically significant difference between the complete mole group and the partial mole group (p=0.76). CONCLUSION: Non-parametric analysis of covariance in terms of cfDNA in GTD was performed, thereby increasing its power and revealing a significant difference compared with the control group. This indicates that maternal peripheral bloodstream cfDNA monitoring might be significant in the early diagnosis of GTD.